Description and comparison of documentation of nursing assessment between paper-based and electronic systems in Australian aged care homes. 2013

Ning Wang, and Ping Yu, and David Hailey
Health Informatics Research Laboratory, School of Information Systems and Technology, Faculty of Informatics, University of Wollongong, Australia.

OBJECTIVE To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment. METHODS This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated. RESULTS Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms). CONCLUSIONS Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.

UI MeSH Term Description Entries
D008297 Male Males
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
D009731 Nursing Audit A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. Audit, Nursing,Audits, Nursing,Nursing Audits
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
D010209 Paper Thin sheets made from wood pulp and other fibrous substances, used for writing, drawing, printing, image duplication or wrapping. Papers
D011785 Quality Assurance, Health Care Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Assessment, Health Care,Health Care Quality Assessment,Health Care Quality Assurance,Healthcare Quality Assessment,Healthcare Quality Assurance,Quality Assessment, Healthcare,Quality Assurance, Healthcare,Assessment, Healthcare Quality,Assessments, Healthcare Quality,Assurance, Healthcare Quality,Assurances, Healthcare Quality,Healthcare Quality Assessments,Healthcare Quality Assurances,Quality Assessments, Healthcare,Quality Assurances, Healthcare
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
D005260 Female Females
D006707 Homes for the Aged Geriatric long-term care facilities which provide supervision and assistance in activities of daily living with medical and nursing services when required. Old Age Homes,Residential Aged Care Facility,Senior Housing,Home, Old Age,Homes, Old Age,Housing, Senior,Old Age Home
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man

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