A meta‐study of the essentials of quality nursing documentation

Abstract

The aim of this study was to synthesize all relevant information about nursing documentation and present the essential aspects of quality nursing documentation. Literature searches, limited to the English language, were conducted on both CINAHL (1982 to week 3, April 2008) and MEDLINE (1996 to April 2008) using the following search terms: attitude, audit, care, culture, documentation, guideline health, in service, legal, liability, medical, nurses, nursing, organizational, patient, personnel, planning practice, quality, records, research and training. One hundred and seventy-one papers were reviewed for their relevance to the clinical question. Twenty-eight articles were read by two researchers. Data informing the clinical question were extracted and categorized into key concepts by an analysis of similarities. The seven major themes (essentials) of quality nursing documentation were identified. This paper has reviewed contemporary literature, research evidence and local policies to identify the seven essential components of quality nursing documentation. Some of the barriers or more controversial aspects of the final policy are described.

Nursing documentation in palliative care: An integrative review

“…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].…”

Strammere journalføring gir bedre pasientoppfølging

“…Her skal opprinnelig problemformulering, ressurskartlegging og forslag til tiltak evalueres. Endringer som gjøres på evalueringsmøtet, skal ende opp i ny og revidert plan (3,8,14,15).…”

“…få frem pasientens opplevelse av sin tilstand, og pasientens respons på tiltak som gjennomføres (3,6,14,16) inneholde relevante og nødvendige opplysninger (17). Irrelevant informasjon skal lukes bort eller plasseres på bedre egnet sted (3,6) først og fremst ta utgangspunkt i tiltaksplanen.…”

“…Irrelevant informasjon skal lukes bort eller plasseres på bedre egnet sted (3,6) først og fremst ta utgangspunkt i tiltaksplanen. Observasjoner som ikke har direkte sammenheng med tiltaksplanen, skal skrives ned, men relevansen skal vurderes i etterkant i størst mulig grad beskrive atferd (for eksempel: «Pasienten sier …»).…”

“…I pasientjournalen viser vi frem hvordan vi utfører faget vårt, og lesing av journaler kan si oss mye om våre faglige prioriteringer. Journalen er en indikator på kvaliteten av sykepleien som utføres (1)(2)(3)(4)(5)(6).…”