Documenting patient risk and nursing interventions: record audit

Abstract

Objective: The aim was to explore and compare documentation of the nursing process for patient safety in two nursing documentation systems: paper and digital records. Background:The 'nursing process' (assessment, planning, intervention, and evaluation) is recommended by professional nursing registration and health service accreditation bodies as a key component of understanding nurses' clinical reasoning. Nurses' responsibility for patient safety must be supported by comprehensive documentation practices. Study design and methods:A retrospective audit of twenty clinical care records (N = 20) randomly selected from a single acute medical ward at a tertiary hospital in Australia; ten from a digital trial that replicated selected paper forms and ten paper records as controls. The audit was conducted by two nurse researchers using a purpose built data extraction tool.Results: Patient age, gender and primary diagnoses were similar for the digital and paper care records. Documentation of the full nursing process was low in both record types, and comprehensiveness of nursing documentation was similar across the paper and digital records. Compared to the paper documents, the digital documents were more often rated as 'complete' (p<0.05). Documentation of risk to skin integrity (p<0.05) and evidence of completed nursing interventions to address risks were more frequent (p<0.05) in digital records. Discussion:The findings of this study highlight an important gap in comprehensive documentation of the nursing process that supports and informs the clinical reasoning of nurses for patient safety. Improvements in digital documents reflect future opportunity to enhance the quality of nurse documentation using technology specific strategies such as prompts, visualisation and nudge. Conclusion:This research identifies that both paper and digital systems of hospital documentation may fail to capture and communicate the clinical reasoning of nurses. Digital systems have the potential to improve capture of the clinical reasoning and nursing process. What is already known about the topic?• Professional registration and healthcare accreditation bodies recommend nurses' clinical decision making is underpinned by processes of assessment, planning, intervention and evaluation. • Poor capture of nurses' clinical decision making in their documentation has negative consequences for the continuity, quality and safety of care; including inadequate detection of deterioration and escalation of care.

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

“…If descriptions of contributing factors connected to the stated ND are provided, they might facilitate better understanding of the nature of the identified problem. This could stimulate nurses’ engagement in the clinical reasoning process of deriving a sound and clinically meaningful ND, as the basis for further care planning [ 22 , 25 ]. Structured documentation that demonstrates how the condition of the residents living with dementia has been understood can contribute to ensuring that they are valued and respected as persons [ 11 ].…”

“…Structured documentation that demonstrates how the condition of the residents living with dementia has been understood can contribute to ensuring that they are valued and respected as persons [ 11 ]. By connecting information about signs and symptoms that led to the NDs into the NCP, nurses in dementia care can identify and implement appropriate interventions to achieve desired person-centered outcomes [ 22 , 39 ].…”

“…Nursing home residents living with dementia often cannot articulate their needs and preferences, and adequate and comprehensive information enables nurses to meet the basic needs of the residents and promotes their well-being [ 6 , 12 ]. Comprehensiveness in nursing documentation is defined as documentation according to the nursing process using an unambigous language [ 7 , 22 ]. The nursing process model, consisting of assessment, diagnosis, planning, implementation, and evaluation is implemented as the basic structure to record nursing care in several EHR systems [ 22 , 23 ].…”

“…Comprehensiveness in nursing documentation is defined as documentation according to the nursing process using an unambigous language [ 7 , 22 ]. The nursing process model, consisting of assessment, diagnosis, planning, implementation, and evaluation is implemented as the basic structure to record nursing care in several EHR systems [ 22 , 23 ]. Sufficient documentation of the core elements in the nursing process may enable nurses in long-term facilities to obtain a more complete picture of the residents and adjust care delivery accordingly [ 24 , 25 ].…”

“…However, the implementation of SNL is in its early stages and has been done partially in Norway [ 28 ]. Despite development of quality critera and positive support for nursing documentation, research in both community and hospital care, show inaccuracies in the recorded content, such as insufficient and incomplete documentation of the nursing process-elements [ 22 , 24 , 29 ], and a lack of recorded person-centered information [ 30 , 31 ]. Lack of adequate content and comprehensiveness in nursing documentation may cause potential misunderstandings and misintrepretations, thus jeopardising the safety of residents [ 6 , 7 ].…”