Improving the quality of nursing documentation at a residential care home: a clinical audit

Abstract

Background Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice. Methods A criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0–3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019. Results None of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95 % confidence interval 0.3–0.6) for “aims for nursing care” to 1.1 (0.9–1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8–1.1) for “evaluation/progress reports” to 1.9 (1.5–2.2) for “nursing assessment on admission”. Conclusions A criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.

[Retracted] Individualized Management of Quality of Care in Orthopedic Nurses Based on Sensitive Indicators

“…According to the epistemology of Marxism, the internal cause is the basis of change, the external cause is the condition of the change, and the external cause works through the internal cause [ 17 ]. Quality is prepared by individual nurses, and continuous improvement of quality is a process of active learning and improvement, rather than a process of passive improvement by individual nurses [ 18 ]. The results show that the index management based on individual nurses can timely feedback the quality level of nurses to individual nurses, making the quality evaluation more scientific and accurate; based on the index evaluation of individual nurses, the index results of all nurses in a certain period of time are summarized to form the overall quality [ 19 ].…”

Guia sobre Sistematização da Assistência e Processo de Enfermagem: tecnologia educacional para a prática profissional

“…Dentre as principais dificuldades para cumprir o preconizado na legislação em relação ao PE, destacam-se a falta de conhecimento teórico, de exercício prático e de recursos, bem como a escassez de tempo para sua realização. As ações dos enfermeiros, muitas vezes, tornam o fazer rotineiro, sem suficiente respaldo científico (6)(7)15) .…”

“…O pouco conhecimento também se mostrou fortemente ligado à falta de desejo dos enfermeiros de implementar o PE na prática clínica. Os fatores gerenciais identificados foram a escassez ou ausência de infraestrutura, o sistema de documentação incompleto, a elevada carga de trabalho da enfermagem, a escassez de recursos humanos, a deficiência de treinamento em serviço, dentre outros fatores (5)(6) . Ainda, a falta de conhecimento teórico, de habilidades e de atitudes em relação à aplicação do PE também é uma das barreiras na realização do PE no ambiente clínico (7) .…”

Efektivitas Intrument D-Cacth sebagai Alat Ukur Dokumentasi Keperawatan: Scoping Review

“…Banyak faktor yang mempengaruhi terjadinya dokumentasi keperawatan yang buruk, salah satunya adalah kurangnya supervisi atau audit dokumentasi dari pimpinan (Obioma et al, 2017). Audit dokumentasi adalah sebuah proses kegiatan yang dilakukan secara kontinu yang bertujuan untuk menilai kualitas asuhans keperawatan yang diberikan oleh perawat secara langsung kepada pasien (Moldskred, Snibsoer, et al, 2021). Menurut Ramukumba & El Amouri (2019) audit dokumentasi dapat memberikan gambaran terkait kualitas asuhan yang telah diberikan kepada pasien.…”

“…Berdasarkan hasil penelitian audit dokumentasi tersebut diketahui bahwa 76,7 % pengkajian keperawatan hanya sebagian yang lengkap dan akurat, sekitar 95,7 % diagnosa yang mengandung masalah keperawatan, hasil analisis keakuratan intervensi keperawatan menunjukkan bahwa tidak ada tindakan/aktifitas keperawatan yang dilakukan (81,3%), keakuratan catatan perkembangan dan evaluasi diketahui sebagian telah lengkap (63,9%) dan legibility/keterbacaan memiliki kualitas yang baik (69,2%). Penelitian terkait audit dokumentasi dengan menggunakan instrument D-Cacth juga pernah dilakukan oleh Moldskred, Snibsoer, et al,(2021) terhadap 38 catatan pasien yang dianalisis sejak Januari hingga Maret 2018. Audit ulang dilakukan pada Maret hingga Juni 2019 setelah dilakukan pengembangan dan penerapan strategi intervensi multifaset.…”