Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. It contains information in accordance with the steps of the nursing process. Nursing documentation is the principal clinical information source to meet legal and professional requirements, care nurses' knowledge of nursing documentation, and is one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients.
Purposes A written record of the history, treatment, care, and response of the client while under the care of a health care provider. A guide for reimbursement of care costs. Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given. Show the use of the nursing process. It contains observations by the nurses about the client's condition, care, and treatment delivered. Provides data for quality assurance studies and shows progress toward expected outcomes.
Documentation of the nursing process
The internationally accepted nursing process consists of five steps: assessment, nursing problem/diagnosis, goal, intervention and evaluation.Björvell C., Thorell-Ekstrand I. Wredling R. Development of an audit instrument for nursing care plans in the client record. Quality in Health Care 2000; 9: 6–13. Nursing process model provides the theoretical framework for nursing documentation. A nurse can follow this model to assess the clinical situation of a client and record a constructive document for nursing communication.
Content Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process.Blair, W., & Smith, B. (n.d). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160–168. The following sections describe the concept, aim, possible structure and content of these nursing documents using the example of nursing documentation in Australian residential aged care homes.
Admission An admission form is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care."General Info". Archived from the original on 12 March 2009. Retrieved 2009-04-03. The form is completed by a nurse when a client is admitted to a health care facility.
The admission form provides the basic information to establish foundations for further nursing assessment. It usually contains the general data about a client, such as name, gender, age, birth date, address, contact, identification information (ID) and some situational descriptions about marriage, work or other background information. Based on the different nursing care provider's requirements, this form may also record family history, past medical history, history of present illness, and allergies in nursing
Assessment The documentation of nursing assessment is the recording of the process about how a judgment was made and its related factors, in addition to the result of the judgment. It makes the process of nursing assessment visible through what is presented in the documentation content.Oroviogoicoechea C., Elliott B. & Watson S. (2008) Review: evaluating information systems in nursing. Journal of Clinical Nursing 17, 567–575.
During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client.Crisp J., Taylor C., Potter P. A. & Perry A. G. (2005) POTTER and PERRY'S fundamentals of nursing (2nd ed). Elsevier Australia. Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process.White L. (2002) Documentation and the Nursing Process. Delmar Learning, Clifton Park, NY.
The nursing documents may contain a number of assessment forms. In an assessment form, a licensed Registered Nurse records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing process.L. White, Documentation and the Nursing Process, Delmar Learning, Clifton Park, NY, 2002.
Nursing care plan The nursing care plan (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients. It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriented rather than nursing-process-based.Greenwood D. (1996) Nursing care plans: issues and solutions. Nursing Management 27(3), 33–40. Nowadays, the NCP is widely used in nursing in various clinical and educational settings as a tool to direct individualized nursing care for clients.Neilson T., Peet M., Ledsham R. & Poole J. (1996) Does the nursing care plan help in the management of psychiatric risk? Journal of Advanced Nursing 24, 1201–1206.
Daly J. M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23.
Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care 9, 6–13.
Kern C. S., Bush K. L. & McCleish J. M. (2006) Mind-mapped care plans: integrating an innovative educational tool as an alternative to traditional care plans. Journal of Nursing Education 45(4), 112–119.Daly J. M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23.Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care 9, 6–13.Kern C. S., Bush K. L. & McCleish J. M. (2006) Mind-mapped care plans: integrating an innovative educational tool as an alternative to traditional care plans. Journal of Nursing Education 45(4), 112–119.
The nurses make nursing care plans based on the assessments they have completed previously with a client. There are many ways of structuring nursing care plans in correspondence with the different needs of nursing care in different nursing specialties. For example, a nursing care plan in an Australian residential aged care home may be structured with several sections under each care domain such as pain, mobility, lifestyle, nutrition and continence. The information is recorded in free-text style, and various terms are used singly or in combination to name each of the four sections in the formats that are used by a facility during a particular period
Progress notes A progress note is the record of nursing actions and observations in the nursing care process."UW Internal Medicine Residency Program". Retrieved 2009-04-10. It helps nurses to monitor and control the course of nursing care.
Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
Recording format
Paper-based nursing documentation The paper-based nursing documentation has been in place for decades. Client's data are recorded in paper documents. The information in these documents needs to be integrated for sense-making in a nursing decision.
Electronic nursing documentation Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery.Zhang Y., Yu P., Shen J. The benefits of introducing electronic health records in residential aged care facilities:A multiple case study. Interna- tional Journal of Medical Informatics 2012; 81: 690–704. In some settings, such systems also include documentation tools that assist nurses with drafting and reviewing care notes during clinical encounters, including ambient documentation systems used alongside electronic records in routine practice by platforms such as Twofold Health and similar services.
Comparison of the quality of paper-based and electronic documentation Electronic nursing documentation systems are able to produce somewhat better quality data in comparison with paper-based systems, in certain respects depending on the characteristics of the systems and the practice of the various study settings. The common benefits of electronic documentation systems include the improvement of comprehensiveness in documenting the nursing process, the use of standardized language and the recording of specific items about particular client issues and relevance of the message. In addition, electronic systems can improve legibility, dating and signing in nursing records.
For the documentation of nursing assessment, the electronic systems significantly increased the quantity and comprehensiveness of documented assessment forms in each record. In regard to the NCP, the electronic standardized NCPs were graded with a higher total quality score than its paper-based counterpart. In addition, in comparison with the paper-based documentation systems, the electronic systems, due to their automatic functions, were able to improve the format, structure and process features of documentation quality such as legibility, signing, dating, crossing out error and space with a single line and resident identification on every page.
Paper-based documentation has been found to be inferior in comparison with electronic documentation. This is caused by the inherent nature of paper being difficult to update, time-consuming in a recording. Thus, the records are often incomplete, illegible, repetitive and missing signatures.Ammenwerth E., Eichstadter R., Haux R. et al. A randomized evaluation of a computer-based nursing documentation system. Method Inform Med 2001; 40: 61–68.
Electronic nursing documentation systems have the potential to improve the quality of documentation structure and format, process and content in comparison with paper-based documentation, as demonstrated in a comparative study of electronic and paper-based nursing admission forms.Wang, N., Yu, P., & Hailey, D. (2012). Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities. International Journal of Medical Informatics, . However, improvement in documentation quality is not necessarily to be brought about by the introduction of electronic nursing documentation system to replace paper-based documentation. For example, Wang et al. that although the electronic nursing assessment form contained more documented assessment forms, which covered a wider range of resident care needs, they did not perform better than the previous [null paper-based assessment forms according to] the quality criteria of [null completeness] and timeliness. Therefore, further work on the usage of the electronic documentation systems may focus on improving form design and usage. There is also a need for improvement in compliance with standards in order to better meet the clients' care needs.
Quality of nursing documentation