Abstract
Nursing documentation is a legal record and a communication for continuity of care. Nurses should understand the implications of incorrect documentation could lead to sentinel events. The study aimed to examine the current practice of nursing care documentation and develop project for improvement. The project conducted from January to March 2014. It was based on the fundamental concepts of assessment; planning; implementation and evaluation. A prospective cross sectional method used to evaluate nursing 'Focus Chart' documents. Two nurses' documentation per unit per day for two weeks was assessed and analyze from all units using the hospital's measurement tool. Findings showed that 980 nurses are providing direct patients care and performing documentation on patients chart. Fifty percent (n= 16) unit has started focus charting and ten units are utilizing narrative and six units using other methods in documentation respectively. Documentation improvement package developed and processes put in place to readdress the documentation concern. The nursing care plan, patient assessment and activity flow sheets were reviewed and recommendation made to nursing administration to use a multidisciplinary approach to develop policies and guidelines on nursing documentation. In addition to provide sustained continuing training opportunities for nurses on effectiveness of documentation.
Highlights
Nursing documentation has both practical and legal implications in patient care quality documentation and correct reporting are essential to enhance efficiency in client care [1]
Nursing system of documentation in response to changes in health-care delivery have evolved in recent years, and advanced technology has affected its expectations, the quality of the documentation is a reflection of the standard of professional practice(s) and an indicator of the skilled and safe care provided which should be timely, meticulous, appropriate, accurate to meet the obligations of registered nursing requirement while minimizing legal involvement due to inaccurate or deficient documentation as attested by majority of nursing researches. [1, 2, 3, 4]
Evidence of studies supported that proper nursing documentation provides evidence of the care delivered being and as part of medico-legal requirement; it builds a database of nursing knowledge that can be used for research and quality assurance purposes; and justifies the cost of nursing in the health care system [8]
Summary
Nursing documentation has both practical and legal implications in patient care quality documentation and correct reporting are essential to enhance efficiency in client care [1]. The ability for the nurses to document in a clear concise, legible and legally careful manner can significantly reduce the risk of misunderstanding and negative patient outcomes related to poor communication [3, 4]. Nurses have to accept that documentation is not separate from nursing care and it is not optional It is an integral part of registered nurses' practices, and an important tool that RNs use to ensure high-quality client care. The term documentation as used in this study refers to: any written information about a patient by the nurse that describes patient status, the care or services provided to that patient
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