The issue of nursing documentation
quality is really significant for nurses both nationally and
internationally. The documentation of
nursing has to, but often doesn't give the rational and critical thinking
behind clinical decisions and interventions, while providing the written
evidence of the progress of the patient. A lot of frameworks are available now
to help with nursing documentation including narrative charting, problem
orientated approaches, clinical pathways and focus notes. However, a lot of
nurses still face barriers to maintaining accurate and legally prudent
documentation.
It has been stated in a review of
nursing documentation of patient care and progress towards achieving outcome
goals that there is a lack of clear and easy to follow information about the
patient's progress. In order to address with this issue, there was an
establishment by a project group to look at different frameworks for nursing
documentation. The purpose of the project was to identify and implement a documentation
framework that would encourage critical thinking and provide evidence of the
rationale for nursing actions utilizing a problem based approach to provide
clear and accurate evidence of patient progress. There is a brief description
in this paper about available literature related to the frameworks mentioned
above, highlights barriers to safe, timely and accurate documentation for
nurses, and this description concludes with an explanation of the framework
chosen as a result of this review.
The quality of nursing documentation
is an important issue for nurses both nationally and internationally. It is
clear from many cases on the New Zealand Health and Disability Commissioner
Website (Health and Disability Commissioner, 2010) that issues related to poor
nursing documentation need to be urgently addressed. Different nursing
documentation methods such as SOAPIE are used to provide frameworks that guide
nursing documentation. However these methods do not necessarily meet the
documentation needs of busy clinical areas in the current health environment
because they focus on single problem entries and patients are often complex
with multiple problems.
Nursing documentation in our organization
has lacked a clear rationale for clinical decisions and evidence of critical
thinking. In order to deal with this issue a project group was established to
look at different methods of nursing documentation. The aim of this project was
to identify a method that would encourage critical thinking by using a problem
based approach. This article provides a summary of the literature reviewed at
the commencement of this project and a summary of the framework chosen as a
result of this review.
The review of literature
Sought to identify current methods of
nursing documentation in order to identify any that could be used to improve
the quality of nursing progress notes. A literature search was performed using
CINAHL and MEDLINE. Key words used included the following; documentation,
progress notes, and nursing reports. The review focused on documentation
methods, problem orientated documentation, barriers to documentation, risk
management, and legal implications. Literature published between 1998 and 2011
was reviewed. Some seminal pieces of literature have been included from 1974 to
1997 as these provide relevant background information. Much of the more recent
literature available is in the form of systematic reviews with a focus on
electronic documentation (Kelly, Brandon, & Dicherty, 2011), audit
instruments (Wang, Hailey and Yu 2011), and accuracy of documentation (Paans,
Nieweg, Vander Schans, & Sermeus, 2011) which have not been discussed in
this paper.
Much of the available literature
accessed was related to nursing documentation within acute care settings and
originated from Europe (Darmer, Ankerson, Neilsen, Landberger &
Lippert, 2006; Ehrenberg & Birgensoson, 2003; Ehrenberg et al, 1996;
Hellesø & Ruland, 2001; Idvall & Ehrenberg, 2002) with a focus on
electronic documentation (Gjevjon & Hellesø, 2010; Kelly, Brandon & Dicherty,
2011; Laitinen, Kaunonen & Astedt-Kurki, 2010; Hyrinen & Saranto,
2009). Several articles were direct translations from their original language
making some of the information hard to decipher and resulting in the original
meaning being lost (Ioanna, Stiliani & Vasiliki, 2007; Karlsen, 2007).
Relevant Australian literature was
sparse and covered issues related to documentation in aged care settings
(Daskein, Moyle & Creedy, 2009; Pelletier, Duffield, & Donoghue, 2005)
and a hospital wide nursing documentation project (Tranter, 2009). A specific
search for New Zealand literature uncovered one publication which outlined the
SOAP method of documentation (Gagan, 2009), and discussed the benefits and
advantages of using this framework. Also present were articles aimed at
providing nurses and other health care professionals with extra guidance about
different methods of documentation and the important components of legally
prudent progress notes (Burgum, 1996; Dimond, 2005b; Grooper & Dicapo,
1995; Griffith, 2004). A variety of guidelines to assist with development of
institutional policies for nursing documentation were also located via the
internet (College of Nurses Ontario, 2005; College of Registered Nurses of
British Columbia, and; Nursing Board of Southern Australia, 2006)
·
Provides staff member,
administrator, or any other members and not only members of the health team
with documentation of the services that have been rendered and supply data that
are essential for program planning and evaluation.
·
To provide the
practitioner with data required for the application of professional services
for the improvement of family’s health.
·
Records are tools of
communication between health workers, the family, and other development
personnel.
·
Effective health records
show the health problem in the family and other factors that affect health.
Thus, it is more than a standardized sheet or a form.
·
A record indicates plans
for future.
·
It provides baseline data
to estimate the long-term changes related to services.
·
Nurses should
develop their own method of expression and form in record writing.
·
Records should be written
clearly, appropriately and legibly.
·
Records should contain
facts based on observation, conversation and action.
·
Select relevant facts and
the recording should be neat, complete and uniform
·
Records are valuable
legal documents and so it should be handled carefully, and accounted for.
·
Records systems are
essential for efficiency and uniformity of services.
·
Records should provide
for periodic summary to determine progress and to make future plans.
·
Records should be written
immediately after an interview.
·
Records are confidential
documents.
Recordkeeping Practices of Nurses and Nursing
Documentation
Information work is a critical part of the medical endeavor.
Strauss and Corbin3 note that trajectory work, as they view
medical care, requires information flow before and after each task or task
sequence to maintain continuity of care. Tasks are not isolated but are
intertwined and build on one another to achieve patient goals. Nurses bear a
large burden in both managing and implementing the interdisciplinary team’s
plan for the patient, as well as documenting the care and progress toward
goals. As a result, nurses spend considerable amounts of time doing information
work. There are several genres of nursing documentation studies: those that
examine recordkeeping practices as a whole, those that examine issues relating
to the documentation (time, content, completeness), and comparative evaluations
of different types of changes in the documentation regime including automation
versus paper. Taken together, these provide both detailed and broad knowledge
of nurses’ recordkeeping practices and highlight the reasons why any change
(manual or computerized) is so difficult to integrate into nursing practice.
Records and reports revels the essential
aspects of service in such logical order so that the new staff may be able to
maintain continuity of service to individuals, families and communities.
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