Prevalence of accurate nursing documentation in patient records

Abstract

Aim. This paper is a report of a study conducted to describe the accuracy of nursing documentation in patient records in hospitals. Background. Accurate nursing documentation enables nurses to systematically review the nursing process and to evaluate the quality of care. Assessing nurses' reports in patient records can be helpful for improving the accuracy of nursing documentation. Method. In 2007-2008, we screened patient records (n = 341) from 35 wards in 10 hospitals in the Netherlands. The D-Catch instrument was used to quantify the accuracy of the (1) record structure, (2) admission data, (3) nursing diagnosis, (4) nursing interventions, (5) progress and outcome evaluations and (6) legibility of nursing reports. Items 2-5 were measured as a sum score of quantity criteria (1-4) and quality criteria (1-4), whereas Items 1 and 6 were measured on a 4-point Likert scale that addressed only quality criteria. Findings. The domain 'accuracy of the interventions' had the lowest accuracy scores: 95% of the records revealed a scale score not higher than 5. However, the domain 'admission' had the highest scores: 80% of the records revealed a scale score over 5. Conclusion. Effective documentation systems that support nurses in linking diagnoses, interventions and progress and outcome evaluations could be helpful. To improve the accuracy of the documentation, further research is needed on what factors influence nursing documentation. Comparable outcomes from other studies indicate that applying our study findings to international contexts might support the development of universal criteria for accurate nursing documentation.

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“…According to Jefferies et al [46], quality nursing documentation must meet seven criteria: (1) patient-centred, (2) contains the actual work of nursing, (3) reflects the nurses' clinical judgment, (4) is presented in a logical sequence, (5) is written in real time, (6) records variances in care and (7) fulfils legal requirements. However, even with this knowledge documentation remains poor [42], with insufficient documentation of; assessment and nursing care and inaccuracy of documentation evident [47]. This is compounded by incongruence between what is documented and the actual physical status of the patient [48] and limited documentation of the work of nurses [35].…”

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“…Resultat og evaluering dokumenteres i større grad når det gjelder omfang og nøyaktig-het enn hva som er tilfellet for dokumentasjon av sykepleiediagnose og tiltak (6,8,16). Samtidig er det enighet om at sykepleieprosessen inneholder de teoretiske elementene for en fullstendig og nøyaktig sykepleiedokumentasjon (8,16).…”