Improving the quality of nursing documentation at a residential care home: a clinical audit

Background

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.

Methods

A 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.

Results

None 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”.

Conclusions

A 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.

Introducing standardised care plans as a new recording tool in municipal health care

AIMS AND OBJECTIVES

To explore how nurses use standardised care plans as a new recording tool in municipal health care, and to identify their thoughts and opinions.

BACKGROUND

In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardised care plans is expected to raise the quality of recorded information, improve overviews, support evidence-based practice and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardised care plans are used as a recording tool in the municipal healthcare setting.

DESIGN

An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research.

METHODS

Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records.

RESULTS

Use of standardised care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for nonuse. There was no consensus regarding how much information to include, and the standardised care plans could become both short and generic, and long and comprehensive. The themes "balancing between the old and the new care planning system," "considering the usefulness of standardised care plans as a source of information" and "balancing between overview and detail" reflect these findings.

CONCLUSIONS

Nurses' use of standardised care plans was influenced by the plans' partial implementation, their views on usefulness and their personal views on the detail required in a care plan.

RELEVANCE TO CLINICAL PRACTICE

The structuring of nursing records is a fast-growing trend in health care. This study gives valuable information for those attempting to implement such structures in municipal health care.

Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital

Discussions on how nursing documentation should be carried out have been ongoing for the last decade. In this study, free-text format for nursing diagnoses was introduced to nursing staff at a university hospital in Norway. The aim of the study was to investigate the impact of an education intervention introducing nursing diagnoses in a free-text format following a problem-etiology-symptom structure. A pretest–posttest design was performed to assess changes in quality and quantity in the nursing documentation using the audit instrument N-Catch II. Several elements in the nursing documentation had statistically significant changes; the largest was found for quantity in nursing diagnoses. Education interventions aimed to improve nurses’ documentation in the electronic health record may have an effect on more complete and accurate nursing documentation. The presented education intervention showed a significant impact of more accurate nursing diagnoses and significant improvements in nursing documentation.