Prevalence of accurate nursing documentation in patient records. 2010

Wolter Paans, and Walter Sermeus, and Roos M B Nieweg, and Cees P van der Schans
Research and Innovation Group in Health Care and Nursing, Hanze Universityof Applied Sciences, Groningen, The Netherlands and Catholic University Leuven, Belgium. w.paans@pl.hanze.nl

OBJECTIVE This paper is a report of a study conducted to describe the accuracy of nursing documentation in patient records in hospitals. Background.  Accurate nursing documentation enables nurses to systematically review the nursing process and to evaluate the quality of care. Assessing nurses' reports in patient records can be helpful for improving the accuracy of nursing documentation. METHODS In 2007-2008, we screened patient records (n = 341) from 35 wards in 10 hospitals in the Netherlands. The D-Catch instrument was used to quantify the accuracy of the (1) record structure, (2) admission data, (3) nursing diagnosis, (4) nursing interventions, (5) progress and outcome evaluations and (6) legibility of nursing reports. Items 2-5 were measured as a sum score of quantity criteria (1-4) and quality criteria (1-4), whereas Items 1 and 6 were measured on a 4-point Likert scale that addressed only quality criteria. RESULTS The domain 'accuracy of the interventions' had the lowest accuracy scores: 95% of the records revealed a scale score not higher than 5. However, the domain 'admission' had the highest scores: 80% of the records revealed a scale score over 5. CONCLUSIONS Effective documentation systems that support nurses in linking diagnoses, interventions and progress and outcome evaluations could be helpful. To improve the accuracy of the documentation, further research is needed on what factors influence nursing documentation. Comparable outcomes from other studies indicate that applying our study findings to international contexts might support the development of universal criteria for accurate nursing documentation.

UI MeSH Term Description Entries
D009426 Netherlands Country located in EUROPE. It is bordered by the NORTH SEA, BELGIUM, and GERMANY. Constituent areas are Aruba, Curacao, and Sint Maarten, formerly included in the NETHERLANDS ANTILLES. Holland,Kingdom of the Netherlands
D009733 Nursing Diagnosis Conclusions derived from the nursing assessment that establish a health status profile for the patient and from which nursing interventions may be ordered. Diagnosis, Nursing,Diagnoses, Nursing,Nursing Diagnoses
D009736 Nursing Process The sum total of nursing activities which includes assessment (identifying needs), intervention (ministering to needs), and evaluation (validating the effectiveness of the help given). Process, Nursing,Nursing Processes,Processes, Nursing
D009737 Nursing Records Data recorded by nurses concerning the nursing care given to the patient, including judgment of the patient's progress. Records, Nursing,Nursing Record,Record, Nursing
D009741 Nursing Staff, Hospital Personnel who provide nursing service to patients in a hospital. Hospital Nursing Staff,Hospital Nursing Staffs,Nursing Staffs, Hospital,Staff, Hospital Nursing,Staffs, Hospital Nursing
D010343 Patient Admission The process of accepting patients. The concept includes patients accepted for medical and nursing care in a hospital or other health care institution. Voluntary Admission,Admission, Patient,Admission, Voluntary,Admissions, Patient,Admissions, Voluntary,Patient Admissions,Voluntary Admissions
D003430 Cross-Sectional Studies Studies in which the presence or absence of disease or other health-related variables are determined in each member of the study population or in a representative sample at one particular time. This contrasts with LONGITUDINAL STUDIES which are followed over a period of time. Disease Frequency Surveys,Prevalence Studies,Analysis, Cross-Sectional,Cross Sectional Analysis,Cross-Sectional Survey,Surveys, Disease Frequency,Analyses, Cross Sectional,Analyses, Cross-Sectional,Analysis, Cross Sectional,Cross Sectional Analyses,Cross Sectional Studies,Cross Sectional Survey,Cross-Sectional Analyses,Cross-Sectional Analysis,Cross-Sectional Study,Cross-Sectional Surveys,Disease Frequency Survey,Prevalence Study,Studies, Cross-Sectional,Studies, Prevalence,Study, Cross-Sectional,Study, Prevalence,Survey, Cross-Sectional,Survey, Disease Frequency,Surveys, Cross-Sectional
D004282 Documentation Systematic organization, storage, retrieval, and dissemination of specialized information, especially of a scientific or technical nature (From ALA Glossary of Library and Information Science, 1983). It often involves authenticating or validating information. Documentations
D006769 Hospitals, General Large hospitals with a resident medical staff which provides continuous care to maternity, surgical and medical patients. General Hospital,General Hospitals,Hospital, General
D006785 Hospitals, University Hospitals maintained by a university for the teaching of medical students, postgraduate training programs, and clinical research. University Hospitals

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