Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review

Abstract

Background Insight into and understanding of content and comprehensiveness in nursing documentation is important to secure continuity and high-quality care planning in long-term dementia care. The accuracy of nursing documentation is vital in areas where residents have difficulties in communicating needs and preferences. This study described the content and comprehensiveness of nursing documentation for residents living with dementia in nursing homes. Methods We used a retrospective chart review to describe content and comprehensiveness in the nursing documentation. Person-centered content related to identity, comfort, inclusion, attachment, and occupation was identified, using an extraction tool derived from person-centered care literature. The five-point Comprehensiveness in the Nursing Documentation scale was used to describe the comprehensiveness of the nursing documentation in relation to the nursing process. Results The residents’ life stories were identified in 16% of the reviewed records. There were variations in the identified nursing diagnoses related to person-centered information, across all the five categories. There were variations in comprehensiveness within all five categories, and inclusion and occupation had the least comprehensive information. Conclusion Findings from this study highlights challenges in documenting person-centered information in a comprehensive way. To improve nursing documentation of residents living with dementia in nursing homes, nurses need to include residents’ perspectives and experiences in their planning and evaluation of care.

Good practice in the provision of care for people living with dementia in nursing homes: a systematic review

“…Of the 30 studies included in the review, 16 were qualitative descriptive studies,(13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28) 11 were cross-sectional studies,(28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38) 2 were mixed methods studies,(39, 40) and 1 was a cohort study. (41) Participants included people living with dementia, relatives, staff working in nursing homes, experts in dementia care, administrators and lawyers.…”

“…Settings were described as nursing homes (n=20), residential care facilities (n=3), dementia care unit (n=3), care homes (n=2), assisted living facility (n=1) and hospital or nursing homes specialised in palliative care (n=1). Studies were conducted in Australia (n = 8),(15, 16, 17, 26, 28, 30, 40, 42) USA (n = 6),(14, 20, 24, 33, 37, 43) UK (n = 5),(19, 20, 21, 39, 42) Norway (n = 4),(18, 23, 27, 29) the Netherlands (n = 2),(31, 35) Denmark (n = 2),(22, 25) New Zealand (n=1)(42) Sweden (n = 2),(34, 36) Canada (n = 1),(32) Northern Ireland (n = 1),(31) Indonesia (n=1)(13), South Africa (n=1),(42) and Malaysia (n = 1). (41) Two of these studies were conducted in multiple jurisdictions.…”

“…This vignette provides examples of quality dementia care from a resident’s point of view. It covers the following themes: determinants of quality care (13, 15, 16, 30, 37, 38, 39), outcomes (18, 30, 39), person-centred care (14, 17, 18, 28, 32, 35, 41, 44), cultural impact (28, 42) care planning (17, 29, 39), meaningful engagement (19, 20), eating and meals (30, 32, 46), the role of family members (15, 17, 31), restrictive practices (26, 30, 38), activities (15, 18, 25, 27, 28, 34), materials (21), health care (14, 23, 31, 40), end of life care (31, 33, 36), staffing (16, 17, 24, 31, 33, 42, 45) and staff training (14, 16, 17, 20, 24, 31, 41, 42).…”

“…This vignette provides examples of quality dementia care from a family member’s point of view. It covers the following themes: outcomes (18, 30, 39), person-centred care (14, 17, 18, 28, 32, 35, 41, 44), care planning (17, 29, 39), the role of family members (15, 17, 31), activities (15, 18, 25, 27, 28, 34) and materials (21).…”

Dampak Penggunaan Dokumentasi Keperawatan Elektronik terhadap Keselamatan Pasien: A Literature Review

“…Studi mengakui beberapa keuntungan penggunaan pencatatan berbasis elektronik berupa efisiensi biaya, pengurangan kesalahan pengobatan, efisiensi biaya, pelacakan data yang baik serta data klinis yang lebih baik (Alpert, 2016). Di sisi lain, penggunaan catatan elektronik dilaporkan berimplikasi terhadap beberapa potensi bahaya berupa penurunan kualitas dokumentasi klinis, peningkatan prevalensi teks yang disalin dan ditempel secara sembarangan dan berulang (Bowman, 2013), serta tantangan lain terlihat dari terbatasnya struktur dan konten yang dimiliki catatan elektronik, sehingga hal ini menyebabkan tantangan dalam melaksanakan pendokumentasian (Laukvik et al, 2022).…”