{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,15]],"date-time":"2026-01-15T10:49:41Z","timestamp":1768474181999,"version":"3.49.0"},"reference-count":32,"publisher":"Wiley","issue":"19-20","license":[{"start":{"date-parts":[[2015,7,14]],"date-time":"2015-07-14T00:00:00Z","timestamp":1436832000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Journal of Clinical Nursing"],"published-print":{"date-parts":[[2015,10]]},"abstract":"<jats:sec><jats:title>Aims and objectives<\/jats:title><jats:p>To compare stroke unit staff members' documentation of care in line with evidence\u2010based guidelines pre\u2010 and postimplementation of a multi\u2010professional, evidence\u2010based standardised care plan for stroke care in the electronic health record.<\/jats:p><\/jats:sec><jats:sec><jats:title>Background<\/jats:title><jats:p>Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence\u2010based practice in hospital.<\/jats:p><\/jats:sec><jats:sec><jats:title>Design<\/jats:title><jats:p>Quantitative, comparative.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Structured retrospective health record reviews were made prior to (<jats:italic>n<\/jats:italic> 60) and one and a half years after implementation (<jats:italic>n<\/jats:italic> 60) of a multi\u2010professional evidence\u2010based standardised care plan with a quality standard for stroke care in the electronic health record.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist\u2010documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>An evidence\u2010based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis.<\/jats:p><\/jats:sec><jats:sec><jats:title>Relevance to clinical practice<\/jats:title><jats:p>Use of a standardised care plan seems to have the potential to help staff adhere to evidence\u2010based patient care and, thereby, to increase patient safety.<\/jats:p><\/jats:sec>","DOI":"10.1111\/jocn.12874","type":"journal-article","created":{"date-parts":[[2015,7,14]],"date-time":"2015-07-14T16:27:30Z","timestamp":1436891250000},"page":"2788-2796","source":"Crossref","is-referenced-by-count":4,"title":["Standardised care plans for in hospital stroke care improve documentation of health care assessments"],"prefix":"10.1111","volume":"24","author":[{"given":"Ulrika","family":"P\u00f6der","sequence":"first","affiliation":[{"name":"Department of Public Health and Caring Sciences Caring Sciences Uppsala University Uppsala Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marie Fogelberg","family":"Dahm","sequence":"additional","affiliation":[{"name":"Unit for Care Development Uppsala University Hospital Uppsala Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nina","family":"Karlsson","sequence":"additional","affiliation":[{"name":"Unit for Care Development Uppsala University Hospital Uppsala Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Barbro","family":"Wadensten","sequence":"additional","affiliation":[{"name":"Department of Public Health and Caring Sciences Caring Sciences Uppsala University Uppsala Sweden"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2015,7,14]]},"reference":[{"key":"e_1_2_11_2_1","first-page":"707601","article-title":"Patients' participation as it appears in the nursing documentation, when care is ruled by standardized care plans","volume":"2011","author":"Andreae C","year":"2011","journal-title":"International Scholarly Research Network Nursing"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1159\/000356346"},{"key":"e_1_2_11_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.iccn.2012.11.002"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1111\/jep.12078"},{"key":"e_1_2_11_6_1","volume-title":"Nursing Diagnosis: Application to Clinical Practice","author":"Carpenito JL","year":"2013"},{"key":"e_1_2_11_7_1","unstructured":"CODEX(2014 Jan 17 2014)Rules and Guidelines for Research. 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