Abstract
Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment (CGA) process which can improve older patients’ outcomes following a hospital admission. Our aim is to understand older person nurses’ experiences of and attitudes to documentation, via semi-structured, in-depth interviews of eight qualified nurses at an acute hospital trust. Interviews were analysed using the framework approach to identify key themes. Three overarching themes were identified: gaps, mishaps and overlaps. Gaps refer to information which was missing, inaccurate or inconsistent; mishaps refer to the consequences of these inaccuracies and inconsistencies; and overlaps refer to the problem of duplications in recording of information. Older person nurses report many inconsistencies, omissions and duplications in their documentation. This has implications for how nursing contributes to the CGA and the quality of care of older patients. New ways must be found to minimise and streamline existing documentation to ensure that records are complete, timely and person-centred. Nurses should be mindful that emerging digital technology systems do not create further problems. Ward nurses need to take greater control of development of documentation.
Highlights
Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment process which can improve older patient’s outcomes following a hospital admission
- Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment process which improves older patient’s outcomes following a hospital admission
Many of these patients have multiple and complex problems compounded by treatments; poorer function and nutritional status; high levels of physical dependency; high prevalence of mental health needs and multiple co-morbidities; all of which require skilled, experienced nursing care which is found to be often difficult and time consuming to deliver in a compassionate way (Zekry et al, 2008; Glover et al, 2014; Goldberg et al, 2012)
Summary
Accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment process which can improve older patient’s outcomes following a hospital admission. A high proportion of acute hospital beds are occupied by older people with figures from the Royal College of Psychiatrists reporting that two-thirds of NHS beds are occupied by people aged 65 years or older and an average district general hospital with 500 beds will admit 5000 older people every year (RCPsych, 2005) Many of these patients have multiple and complex problems compounded by treatments; poorer function and nutritional status; high levels of physical dependency; high prevalence of mental health needs and multiple co-morbidities; all of which require skilled, experienced nursing care which is found to be often difficult and time consuming to deliver in a compassionate way (Zekry et al, 2008; Glover et al, 2014; Goldberg et al, 2012). A study by Moody et al (2004) assessed the attitudes of one hundred nurses towards electronic documentation and found that seventy five percent of nurses believed it to improve the quality of documentation.
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
