Abstract
BackgroundQuality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice.MethodsA criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0–3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019.ResultsNone of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95 % confidence interval 0.3–0.6) for “aims for nursing care” to 1.1 (0.9–1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8–1.1) for “evaluation/progress reports” to 1.9 (1.5–2.2) for “nursing assessment on admission”.ConclusionsA criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.
Highlights
Quality in nursing documentation holds promise to increase patient safety and quality of care
While digital nursing documentation can be structured in different ways, the majority of electronic nursing records has been shown to be organised according to the nursing process [2, 4]
We focused on the quantitative assessment of the documentation, assessing the following steps in the nursing process; ”Nursing assessment on admission”, “Nursing diagnoses”, “Aims for nursing care”, “Nursing interventions”, and “Evaluation/progress report” (Table 1)
Summary
Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice. The step-wise process includes assessment of the patient, nursing diagnoses and goals, planning, nursing interventions and evaluation of practice. This forms the basis of nursing documentation as a care plan [6]. In nursing practice the patient may have several problems, with each requiring different descriptions of nursing problems, or diagnoses [5]
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