Patient medication--How is it documented?

Abstract

The purpose of this study was to find out how nurses use the standardized terminology of the Finnish Classification of Nursing Interventions (FiCNI) in describing their patients' medication. The main focus was on the use of the FiCNI component Medication and its various categories in daily documentation. The data were collected during a ten-month period in 2003 from electronic nursing care plans drawn up for patients of different ages (N = 1,157). The anonymous data were gathered on five psychiatric, two surgical and two medical wards, one children's intensive care unit as well as one surgical and one medical outpatient clinic at one central hospital. Data analysis was by descriptive statistical methods, and "Drug Administration per os" interventions including narrative text were further classified by means of content analysis. The main categories of the Medication component were used to describe medication administration, side effects and medication counselling. However the subcategories were more commonly used in descriptions of daily care than the main categories. Subcategories were most typically complemented with narrative descriptions of prescribed drugs, time, cause and routes of delivery.