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Nursing documentation in long-term care settings: New empirical evidence demands changes be made. 2014

Philippe Voyer, and Jane McCusker, and Martin G Cole, and Johanne Monette, and Nathalie Champoux, and Antonio Ciampi, and Eric Belzile, and Minh Vu, and Sylvie Richard
Faculty of Nursing Sciences, Laval University, Quebec City, QC, Canada Centre for Excellence in Aging-Research Unit, Quebec City, QC, Canada philippe.voyer@fsi.ulaval.ca.

In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above (N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident-nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses' work overload.

UI MeSH Term Description Entries
D008134 Long-Term Care Care over an extended period, usually for a chronic condition or disability, requiring periodic, intermittent, or continuous care. Care, Long-Term,Long Term Care
D009730 Nursing Assessment Evaluation of the nature and extent of nursing problems presented by a patient for the purpose of patient care planning. Nursing Protocols,Assessment, Nursing,Protocols, Nursing,Assessments, Nursing,Nursing Assessments,Nursing Protocol,Protocol, Nursing
D009735 Nursing Homes Facilities which provide nursing supervision and limited medical care to persons who do not require hospitalization. Homes, Nursing,Nursing Home
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
D011792 Quebec A province of eastern Canada. Its capital is Quebec. The region belonged to France from 1627 to 1763 when it was lost to the British. The name is from the Algonquian quilibek meaning the place where waters narrow, referring to the gradually narrowing channel of the St. Lawrence or to the narrows of the river at Cape Diamond. (From Webster's New Geographical Dictionary, 1988, p993 & Room, Brewer's Dictionary of Names, 1992, p440)
D003693 Delirium A disorder characterized by CONFUSION; inattentiveness; disorientation; ILLUSIONS; HALLUCINATIONS; agitation; and in some instances autonomic nervous system overactivity. It may result from toxic/metabolic conditions or structural brain lesions. (From Adams et al., Principles of Neurology, 6th ed, pp411-2) Delirium of Mixed Origin,Subacute Delirium,Delirium, Subacute,Deliriums, Subacute,Mixed Origin Delirium,Mixed Origin Deliriums,Subacute Deliriums
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D000368 Aged A person 65 years of age or older. For a person older than 79 years, AGED, 80 AND OVER is available. Elderly
D036262 Empirical Research The study, based on direct observation, use of statistical records, interviews, or experimental methods, of actual practices or the actual impact of practices or policies. Research, Empirical

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