Accuracy of documentation in the nursing care plan in long-term institutional care

Astrid Tuinman, Mathieu H G de Greef, Wim P Krijnen, Wolter Paans, Petrie F Roodbol

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Inadequacies were especially found in the description of residents' care needs and stated nursing diagnoses as well as in progress and outcome reports. In somatic and psycho-geriatric units, higher accuracy scores were determined compared with residential care units. Investments in resources (e.g., time), reasoning skills of nursing staff, and implementation of professional standards in accordance with legal requirements may be needed to enhance the quality of nursing documentation.

Original languageEnglish
Pages (from-to)578-583
JournalGeriatric nursing
Volume38
Issue number6
DOIs
Publication statusPublished - 1 Nov 2017

Keywords

  • nursing
  • documentation
  • planning

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