Prevalence of accurate nursing documentation in patient records

Wolter Paans, Walter Sermeus, Roos Nieweg, Cees van der Schans

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

AIM: This paper is a report of a study conducted to describe the accuracy of nursing documentation in patient records in hospitals. Background.  Accurate nursing documentation enables nurses to systematically review the nursing process and to evaluate the quality of care. Assessing nurses' reports in patient records can be helpful for improving the accuracy of nursing documentation.

METHOD: In 2007-2008, we screened patient records (n = 341) from 35 wards in 10 hospitals in the Netherlands. The D-Catch instrument was used to quantify the accuracy of the (1) record structure, (2) admission data, (3) nursing diagnosis, (4) nursing interventions, (5) progress and outcome evaluations and (6) legibility of nursing reports. Items 2-5 were measured as a sum score of quantity criteria (1-4) and quality criteria (1-4), whereas Items 1 and 6 were measured on a 4-point Likert scale that addressed only quality criteria.

FINDINGS: The domain 'accuracy of the interventions' had the lowest accuracy scores: 95% of the records revealed a scale score not higher than 5. However, the domain 'admission' had the highest scores: 80% of the records revealed a scale score over 5.

CONCLUSION: Effective documentation systems that support nurses in linking diagnoses, interventions and progress and outcome evaluations could be helpful. To improve the accuracy of the documentation, further research is needed on what factors influence nursing documentation. Comparable outcomes from other studies indicate that applying our study findings to international contexts might support the development of universal criteria for accurate nursing documentation.

Original languageEnglish
Pages (from-to)2481-2489
JournalJournal of advanced nursing
Volume66
Issue number11
DOIs
Publication statusPublished - Nov 2010

Keywords

  • Cross-Sectional Studies
  • Documentation
  • Hospitals, General
  • Hospitals, University
  • Humans
  • Netherlands
  • Nursing Diagnosis
  • Nursing Methodology Research
  • Nursing Process
  • Nursing Records
  • Nursing Staff, Hospital
  • Patient Admission
  • Retrospective Studies
  • Journal Article
  • Research Support, Non-U.S. Gov't

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