An Audit of Nursing Documentation at Three Public Hospitals in Jamaica

Abstract

The study provides valuable information for the development of strategic risk management programs geared at improving the quality of care delivered to clients and presents an opportunity for nurse leaders to implement structured interventions geared at improving nursing documentation in Jamaica. In light of Jamaica's epidemiologic transition of chronic diseases, gaps in nurses' documentation of client assessment, patient teaching, and discharge planning should be addressed with urgency. Patient teaching and discharge planning enable the clients to participate more effectively in their health maintenance process.

Use of Electronic and Paper‐based Standardized Nursing Care Plans to Improve Nurses’ Documentation Quality in a Nigerian Teaching Hospital

“…Providing information about care received by patient is vital to providing quality and continuity of care. Information provided can be used to plan, evaluate, and predict the quality of nursing care for a given population when measured retrospectively through audit of documented reports (Donabedian, ; Lindo et al., ). While quality care is said to be less expensive, better, more efficient, and less wasteful (Andel, Davidow, Hollander, & Moreno, ), poor quality care is associated with high cost of hospital care and poorer care outcomes (Canadian Medical Protective Association, ) and has been related with poor quality documentation (Lavin, Harper, & Barr, ).…”

Medical‐surgical nurses’ documentation of client teaching and discharge planning at a Jamaican hospital

“…; Lindo et al. ). These findings are indicative of a broader problem and are concerning given the health and economic implications of the chronic disease epidemic across the Caribbean.…”

“…; Lindo et al. ), with client history and elements of biographical data remaining the strongest areas of documentation, as age and gender were recorded most frequently.…”

“…Evaluating nursing documentation presents an opportunity to measure the quality of client care in the hospital and address gaps in care through evidence‐based interventions (Lindo et al. ; RNAO ; Weiss ). Nurse managers hold the responsibility to uphold documentation standards by conducting audits, appraisals and workshops and developing key alignments to influence policy to improve current practices (Duclos‐Miller ).…”

“…This transition process may be hampered if nursing documentation is incomplete or has fragmented intervention details, partial client teaching exchanges and/or the absence of discharge planning records (Collins et al 2013;Ward 2012). Evaluating nursing documentation presents an opportunity to measure the quality of client care in the hospital and address gaps in care through evidence-based interventions (Lindo et al 2016;RNAO 2014;Weiss 2007). Nurse managers hold the responsibility to uphold documentation standards by conducting audits, appraisals and workshops and developing key alignments to influence policy to improve current practices (Duclos-Miller 2016).…”