Nursing documentation in nursing homes--state-of-the-art and implications for quality improvement.

Stakes (National Research and Development Centre for Welfare and Health)/Policy and Services for Ageing People, Helsinki, Finland.
Scandinavian Journal of Caring Sciences (Impact Factor: 0.89). 04/2004; 18(1):72-81. DOI: 10.1111/j.1471-6712.2004.00265.x
Source: PubMed

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: To develop an Australian nursing documentation in aged care (Quality of Australian Nursing Documentation in Aged Care (QANDAC)) instrument to measure the quality of paper-based and electronic resident records. The instrument was based on the nursing process model and on three attributes of documentation quality identified in a systematic review. The development process involved five phases following approaches to designing criterion-referenced measures. The face and content validities and the inter-rater reliability of the instrument were estimated using a focus group approach and consensus model. The instrument contains 34 questions in three sections: completion of nursing history and assessment, description of care process and meeting the requirements of data entry. Estimates of the validity and inter-rater reliability of the instrument gave satisfactory results. The QANDAC instrument has a potential as a useful audit tool for the purposes of quality improvement and research in aged care documentation.
    Australasian Journal on Ageing 09/2013; · 0.94 Impact Factor
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    Dataset: Wang2013AJA