Nursing documentation in nursing homes – state‐of‐the‐art and implications for quality improvement
ABSTRACT This study was designed to gain information on the quality of nursing care based on the comments in nursing records. The specific aims of the study were to find out if the patients‘ (i) individual needs are assessed, the goals for nursing care are set, and the nursing interventions are determined; (ii) if the patients’ needs are met and (iii) if goal achievement is regularly evaluated by including comments in nursing documents. In addition, the study aimed to describe the up-to-dateness of nursing care plans as well as the frequency of making daily notes. The data were collected on 36 wards of four residential homes. A 30% sample of the nursing documents on each ward was collected (n = 332) using the Senior Monitor instrument. The documents studied were mainly nursing care plans and daily note sheets. Seventy-three per cent of the nursing home residents had an up-to-date nursing care plan at the time of data collection. The main results demonstrated that a written statement on the patient's mental ability was lacking in every fourth document although 75% of the patients suffer from at least moderate dementia in Finnish long-term care institutions. Development activities should also be targeted to the documentation of clear and concrete means by which patients’ independent functioning is supported. In addition, evaluation was the area that warranted attention and development activities since only every fourth record included information on changes in the patients’ functional capability. Although a lot of in-service training has been focused on improving the documentation practices, there is still a need for development. The means by which knowledge is transferred to guide the practice should be carefully considered. Also forms should be developed to meet the special requirements for recording nursing care in long-term care settings.
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ABSTRACT: Nursing documentation is essential for facilitating the flow of information to guarantee continuity, quality and safety in care. High-quality nursing documentation is frequently lacking; the implementation of computerized decision support systems is expected to improve clinical practice and nursing documentation. The present study aimed at investigate the effects of a computerized decision support system and an educational program as intervention strategies for improved nursing documentation practice on pressure ulcers and malnutrition in nursing homes. An intervention study with two intervention groups and one control group was used. Fifteen nursing homes in southern Norway were included. A convenience sample of electronic healthcare records from 46 units was included. Inclusion criteria were records with presence of pressure ulcers and/or malnutrition. The residents were assessed before and after an intervention of a computerized decision support system in the electronic healthcare records. Data were collected through a review of 150 records before (2007) and 141 records after the intervention (2009). The nurses in intervention group 1 were offered educational sessions and were trained to use the computerized decision support system, which they used for eight months in 2008 and 2009. The nurses in intervention group 2 were offered the same educational program but did not use the computerized decision support system. The nurses in the control group were not subject to any intervention. The resident records were examined for the completeness and comprehensiveness of the documentation of pressure ulcers and malnutrition with three data collection forms and the data were analyzed with non-parametric statistics. The implementation of the computerized decision support system and the educational program resulted in a more complete and comprehensive documentation of pressure ulcer- and malnutrition-related nursing assessments and nursing interventions. This study provides evidence that the computerized decision support system and an educational program as implementation strategies had a positive influence on nursing documentation practice.International Journal of Medical Informatics 07/2013; 82(10). DOI:10.1016/j.ijmedinf.2013.05.009 · 2.72 Impact Factor
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ABSTRACT: Aims and objectives To evaluate structured patient assessment frameworks' impact on patient care. Background Accurate patient assessment is imperative to determine the status and needs of the patient and the delivery of appropriate patient care. Nurses must be highly skilled in conducting timely and accurate patient assessments to overcome environmental obstacles and deliver quality and safe patient care. A structured approach to patient assessment is widely accepted in everyday clinical practice, yet little is known about the impact structured patient assessment frameworks have on patient care. DesignIntegrative review. Methods An electronic database search was conducted using Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System, PubMed and ProQuest Dissertations and Theses. The reference sections of textbooks and journal articles on patient assessment were manually searched for further studies. A comprehensive peer review screening process was undertaken. Research studies were selected that evaluated the impact structured patient assessment frameworks have on patient care. Studies were included if frameworks were designed for use by paramedics, nurses or medical practitioners working in prehospital or acute in-hospital settings. ResultsTwelve studies met the inclusion criteria. There were no studies that evaluate the impact of a generic nursing assessment framework on patient care. The use of a structured patient assessment framework improved clinician performance of patient assessment. Limited evidence was found to support other aspects of patient care including documentation, communication, care implementation, patient and clinician satisfaction, and patient outcomes. Conclusion Structured patient assessment frameworks enhance clinician performance of patient assessment and hold the potential to improve patient care and outcomes; however, further research is required to address these evidence gaps, particularly in nursing. Relevance to clinical practiceAcute care clinicians should consider using structured patient assessment frameworks in clinical practice to enhance their performance of patient assessment.Journal of Clinical Nursing 05/2013; 22(21-22). DOI:10.1111/jocn.12226 · 1.23 Impact Factor
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ABSTRACT: This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation. Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings. Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010. A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted. Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality. Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.Journal of Advanced Nursing 04/2011; 67(9):1858-75. DOI:10.1111/j.1365-2648.2011.05634.x · 1.69 Impact Factor