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Sunday, November 1, 2009: 2:45 PM
Learning Objective 1: give an overview of the measurement process of nursing documentation in the patient record, based on a measurement with the D-Catch instrument.
Learning Objective 2: characterize the nature of nursing documentation in hospitals, based on a measurement in the Netherlands.
Abstract
AIM. To determine the accuracy of the nursing documentation in patient records in general hospitals, including admission information, nursing diagnoses, interventions, and progress and outcome evaluations in patient records in general hospitals.
BACKGROUND. Nursing documentation is essential for quality of care; therefore it is important that the documentation is accurate. Accurate documentation contains admission information, structured diagnoses, formulated with a problem label, a cause (related factor) and signs and symptoms accomplished with nursing interventions and progress and outcome evaluations, linked to a diagnosis (1).
METHOD. Record screening of 341 patient records was conducted in 35 wards in 10 hospitals in the Netherlands using the D-Catch measurement instrument which includes the following aspects: 1) Record structure, 2) Admission data, 3) Nursing diagnosis, 4) Nursing interventions, 5) Progress and outcome evaluations, 6) Legibility (readable handwriting or well typed).
FINDINGS. Lowest median accuracy scores were found on the documentation of the interventions 3 (2-8), highest median scores were found on the admission, progress and outcome evaluation, both 6 (2-8). Based on factor analyses two constructs were established. As a result of aggregation and recoding the scale scores to a 100-point scale, a mean score of 54 (sd 15) on the chronological, evaluative construct and of 40 (sd 27) on the diagnostic construct was found.
CONCLUSIONS. Nursing documentation is generally poor to moderate and seems to be mainly chronological and evaluative in nature and less problem-focused. Records with several accurate diagnoses in most cases also contained inaccurate diagnoses. Progress and outcome evaluations were in most cases linked to a diagnosis, though these evaluations were not strictly written as a reflection on the diagnosis, but more as a general evaluation of the patient’s health status.
1.) Carpenito-Moyet, L.J. (2008) Nursing Diagnosis: Application to Clinical Practice, 12th edition, Wolters Kluwer, Lippincott, New York, p. 2-8.
AIM. To determine the accuracy of the nursing documentation in patient records in general hospitals, including admission information, nursing diagnoses, interventions, and progress and outcome evaluations in patient records in general hospitals.
BACKGROUND. Nursing documentation is essential for quality of care; therefore it is important that the documentation is accurate. Accurate documentation contains admission information, structured diagnoses, formulated with a problem label, a cause (related factor) and signs and symptoms accomplished with nursing interventions and progress and outcome evaluations, linked to a diagnosis (1).
METHOD. Record screening of 341 patient records was conducted in 35 wards in 10 hospitals in the Netherlands using the D-Catch measurement instrument which includes the following aspects: 1) Record structure, 2) Admission data, 3) Nursing diagnosis, 4) Nursing interventions, 5) Progress and outcome evaluations, 6) Legibility (readable handwriting or well typed).
FINDINGS. Lowest median accuracy scores were found on the documentation of the interventions 3 (2-8), highest median scores were found on the admission, progress and outcome evaluation, both 6 (2-8). Based on factor analyses two constructs were established. As a result of aggregation and recoding the scale scores to a 100-point scale, a mean score of 54 (sd 15) on the chronological, evaluative construct and of 40 (sd 27) on the diagnostic construct was found.
CONCLUSIONS. Nursing documentation is generally poor to moderate and seems to be mainly chronological and evaluative in nature and less problem-focused. Records with several accurate diagnoses in most cases also contained inaccurate diagnoses. Progress and outcome evaluations were in most cases linked to a diagnosis, though these evaluations were not strictly written as a reflection on the diagnosis, but more as a general evaluation of the patient’s health status.
1.) Carpenito-Moyet, L.J. (2008) Nursing Diagnosis: Application to Clinical Practice, 12th edition, Wolters Kluwer, Lippincott, New York, p. 2-8.