Improving Nursing Documentation

Abstract

Background Audits in 2008 and 2009 show documentation was incomplete in 50% and 57% of cases: below an ideal standard of 91-100%. Omissions were due to poor utility by nurses and unsuitable pro-forma design, (duplication, lack of clarity, haphazard) and time consuming when transcribing to additional sheets at discharge. Nurses re-designed their pages which redressed problems highlighted and facilitated its use at discharge to community Health Care Professionals (HCPs). The resultant pro-forma was audited. Aim To ascertain completion of the new documentation compared with previous audits, confirm its use to community HCPs, and identify areas for improvement. Method The documentation was audited retrospectively using a copy of the pro-forma as the audit tool. Analysis was RAG rated: RED less than 70% completed, least acceptable, actions required. AMBER 70% -90% completed, acceptable but scope for improvement. GREEN 91% -100% completed, ideal standard. Results 15 sets of notes were audited (65% of one month's admissions). Data were collected on pages completed by nurses, which totalled 117 fields. Overall, 74% of the fields achieved either GREEN or AMBER status with the remaining 26% in the RED. Information commonly omitted related to community services, such as was the patient registered as 'palliative' with their out-of-hours GP provider, community HCP's contact details, and care planning post discharge. Data missing on admission included; co-morbidities, metastasises, contact numbers and expected discharge date. Results for tests/investigations were not documented in most cases. Each patient's community HCPs were sent a copy on discharge. Conclusion Significant improvements made using the new documentation; 26% in the RED compared with 100% in both pervious audits. Patient information is more succinct, de-duplicated, streamlined, and comprehensive enough to use at discharge to community HCPs; a survey of the latter underway. Nurses encouraged, and are, more diligent in recording information. Community information pending further review.

Development and Evaluation of an Electronic Nursing Documentation System

“…But, in this survey, 82% of nurses stated that their time was saved by using the developed system in this study. In our study, Nurses' satisfaction with lling nursing report documentation at the patient's bedside, and exchange information from one shift to another shift were 93% and 79%, respectively (12). In other words, lling or documentation the nursing report at the bedside and exchanging patient information from one shift to another are two important features of a nursing report and these features were considered in our designed system.…”

“…In most cases, there is no legislative defense for nursing staff because of the gradual fading and illegibility of manual records (8,9). A nursing report is a routine event that takes place several times across the nurse's daily work so that nurses spend about 37% of their entire time working to writing nursing reports (10)(11)(12).…”

Development and evaluation of an electronic nursing documentation system

“…However, in this survey, 82% of the nurses stated that their time was saved by utilizing the system developed in this study. In our study, nurses’ satisfaction with filling nursing report documentation at the patients’ bedside, and exchanging information from one shift to another shift were 93 and 79%, respectively [ 12 ]. In other words, filling or documentation of the clinical nursing report at the patients’ bedside and exchanging patient information across shifts are two important features of a nursing report that were taken into account in our designed system.…”

“…In most cases, there is no legislative defense for the nursing staff because of the gradual fading and illegibility of manual records [8,9]. Writing a nursing report is a routine event that that should be performed several times during a nurse's daily work, therefore, nurses spend about 37% of their entire working time writing reports [10][11][12]. One-half of all nurses must stay at work for 1-2 h after the end of their shifts, mainly to complete nursing records [13].…”