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| {{Globalize|date=February 2018}} | | {{Short description|The process of recording patient care in nursing}} |
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| '''Nursing documentation''' is the record of [[Nursing|nursing care]] that is planned and delivered to individual [[Patient|clients]] by qualified nurses or other [[caregiver]]s under the direction of a qualified nurse.<ref>Urquhart C, Currell R, Grant MJ. Hardiker NR. Nursing record systems: Effects on nursing practice and healthcare outcomes. Cochrane Data- base of Systematic Reviews 2009; (1): 1–66. </ref> It contains information in accordance with the steps of the [[nursing process]]. Nursing documentation is the principal clinical information source to meet legal and professional requirements,<ref>Daskein R,Moyle W, Creedy D.Aged-care nurses' knowledge of nursing documentation: An Australian perspective. Journal of Clinical Nursing 2009; 18: 2087–2095. </ref> and one of the most significant components in nursing care. Quality nursing documentation plays a vital role in the delivery of quality nursing care services through supporting better communication between different care team members to facilitate continuity of care and safety of the clients. | | '''Nursing documentation''' is a critical component of healthcare that involves the accurate and comprehensive recording of patient care activities and observations by [[nurses]]. It serves as a vital communication tool among healthcare providers and is essential for ensuring continuity of care, legal protection, and quality improvement. |
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| ==Purposes== | | ==Purpose of Nursing Documentation== |
| * A [[Medical record|written record]] of the history, treatment, care, and response of the client while under the care of a health care provider.
| | Nursing documentation serves several key purposes: |
| * A guide for reimbursement of care costs.
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| * Evidence of care in a court of law. A legal record that can be used as evidence of events that occurred or treatments given.
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| * Show the use of the nursing process. It contains observations by the nurses about the client's condition, care, and treatment delivered.
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| * Provides data for quality assurance studies and shows progress toward expected outcomes.
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| == Documentation of the nursing process ==
| | * '''Communication''': It facilitates effective communication among healthcare team members, ensuring that all providers have access to the same information about a patient's condition and care. |
| {{See also|Nursing process}}
| | * '''Legal Record''': Documentation provides a legal record of the care provided, which can be crucial in the event of legal proceedings. |
| | * '''Quality Assurance''': It is used for quality assurance and improvement purposes, helping to identify areas for improvement in patient care. |
| | * '''Research and Education''': Nursing documentation can be used for research and educational purposes, contributing to the advancement of nursing knowledge and practice. |
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| The internationally accepted nursing process consists of five steps: [[Nursing assessment|assessment]], nursing problem/diagnosis, goal, intervention and evaluation.<ref>Björvell C,Thorell-Ekstrand I.Wredling R.Development of an audit instrument for nursing care plans in the client record. Quality in Health Care 2000; 9: 6–13.</ref> Nursing process model provides the theoretical framework for nursing documentation. A nurse can follow this model to assess the clinical situation of a client and record a constructive document for nursing communication.
| | ==Components of Nursing Documentation== |
| | Nursing documentation typically includes the following components: |
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| ==Content==
| | * '''Patient Identification''': Information such as the patient's name, age, and medical record number. |
| Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous [[Assessment for Effective Intervention|assessment forms]], nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the [[nursing process]].<ref>Blair, W., & Smith, B. (n.d). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168.</ref> The following sections describe the concept, aim, possible structure and content of these nursing documents using the example of nursing documentation in Australian residential [[aged care]] homes.
| | * '''Assessment Data''': Observations and assessments made by the nurse, including vital signs, physical examination findings, and patient history. |
| | * '''Nursing Diagnoses''': Identification of patient problems that require nursing intervention. |
| | * '''Care Plan''': A detailed plan outlining the nursing interventions to be implemented. |
| | * '''Interventions''': Documentation of the specific nursing actions taken. |
| | * '''Evaluation''': Assessment of the patient's response to the interventions and any changes in the care plan. |
| | * '''Progress Notes''': Ongoing documentation of the patient's status and any changes in condition. |
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| === Admission === | | ==Types of Nursing Documentation== |
| An [[admission note|admission form]] is a fundamental record in nursing documentation. It documents a client's status, reasons why the client is being admitted, and the initial instructions for that client's care.<ref> "General Info". Archived from the original on 12 March 2009. Retrieved 2009-04-03</ref> The form is completed by a nurse when a client is admitted to a [[Health facility|health care facility]].
| | There are several types of nursing documentation, each serving different purposes: |
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| The admission form provides the basic information to establish foundations for further nursing assessment. It usually contains the general data about a client, such as name, gender, age, birth date, address, contact, identification information (ID) and some situational descriptions about marriage, work or other background information. Based on the different nursing care provider's requirements, this form may also record [[Family history (medicine)|family history]], [[past medical history]], [[History of the present illness|history of present illness]], and allergies (see Figure 1).
| | * '''Narrative Notes''': A chronological account of patient care in a narrative format. |
| [[File:Figure 1. A sample admission.png|thumb|Figure 1. A sample admission form for an Australian residential aged care home.]]
| | * '''SOAP Notes''': A structured format that includes Subjective, Objective, Assessment, and Plan components. |
| | * '''PIE Notes''': Focuses on Problem, Intervention, and Evaluation. |
| | * '''Focus Charting''': Centers on specific patient concerns or behaviors. |
| | * '''Electronic Health Records (EHRs)''': Digital systems that allow for comprehensive and integrated documentation. |
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| === Assessment === | | ==Challenges in Nursing Documentation== |
| The documentation of nursing assessment is the recording of the process about how a judgment was made and its related factors, in addition to the result of the judgment. It makes the process of nursing assessment visible through what is presented in the documentation content.<ref>Oroviogoicoechea C., Elliott B. & Watson S. (2008) Review: evaluating information systems in nursing. Journal of Clinical Nursing 17, 567–575.</ref>
| | Nurses face several challenges in maintaining accurate and comprehensive documentation: |
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| During nursing assessment, a nurse systematically collects, verifies, analyses and communicates a health care client's information to derive a nursing diagnosis and plan individualized nursing care for the client.<ref>Crisp J., Taylor C., Potter PA. & Perry A.G. (2005) POTTER and PERRY'S fundamentals of nursing (2nd ed). Elsevier Australia.</ref> Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process.<ref name="White L. 2002">White L. (2002) Documentation and the Nursing Process. Delmar Learning, Clifton Park, NY</ref>
| | * '''Time Constraints''': Nurses often have limited time to complete documentation due to high patient loads and other responsibilities. |
| | * '''Complexity of Care''': The complexity of modern healthcare can make documentation more challenging. |
| | * '''Technological Issues''': Technical problems with electronic systems can hinder effective documentation. |
| | * '''Legal and Ethical Considerations''': Ensuring that documentation is both legally sound and ethically appropriate. |
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| The nursing documents may contain a number of assessment forms. In an assessment form, a licensed [[Registered nurse|Registered Nurse]] records the client's information, such as physiological, psychological, sociological, and spiritual status (see Figure 2). The accuracy and completeness of nursing assessment determine the accuracy of care planning in the nursing process.<ref> L. White, Documentation and the Nursing Process, Delmar Learning, Clifton Park, NY, 2002.</ref>
| | ==Best Practices for Nursing Documentation== |
| [[File:Figure 2-1. A sample nursing assessment form for an Australian residential aged care home..png|thumb|Figure 2-1. A sample nursing assessment form for an Australian residential aged care home.]]
| | To ensure high-quality documentation, nurses should adhere to the following best practices: |
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| === Nursing care plan ===
| | * '''Accuracy''': Ensure that all information is accurate and reflects the patient's current condition. |
| The [[nursing care plan]] (NCP) is a clinical document recording the nursing process, which is a systematic method of planning and providing care to clients.<ref name="White L. 2002"/> It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriented rather than nursing-process-based.<ref>Greenwood D. (1996) Nursing care plans: issues and solutions. Nursing Management 27(3), 33-40.</ref> Nowadays, the NCP is widely used in nursing in various clinical and educational settings as a tool to direct individualized nursing care for clients.<ref>Neilson T., Peet M., Ledsham R. & Poole J. (1996) Does the nursing care plan help in the management of psychiatric risk? Journal of Advanced Nursing 24,1201-1206
| | * '''Timeliness''': Document care as soon as possible after it is provided. |
| | * '''Clarity''': Use clear and concise language to avoid misunderstandings. |
| | * '''Confidentiality''': Protect patient privacy by adhering to [[HIPAA]] regulations and other privacy laws. |
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| Daly J.M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23.
| | ==Related Pages== |
| | | * [[Nursing process]] |
| Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care 9, 6-13.
| | * [[Electronic health record]] |
| | | * [[Patient safety]] |
| Kern C.S., Bush K.L. & McCleish J.M. (2006) Mind-mapped care plans: integrating an innovative educational tool as an alternative to traditional care plans. Journal of Nursing Education 45(4), 112-119.
| | * [[Healthcare quality]] |
| </ref><ref>Daly J.M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23.</ref><ref>Björvell C., Thorell-Ekstrand I. & Wredling R. (2000) Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care 9, 6-13.</ref><ref>Kern C.S., Bush K.L. & McCleish J.M. (2006) Mind-mapped care plans: integrating an innovative educational tool as an alternative to traditional care plans. Journal of Nursing Education 45(4), 112-119.</ref>
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| The nurses make nursing care plans based on the assessments they have completed previously with a client. There are many ways of structuring nursing care plans in correspondence with the different needs of nursing care in different nursing specialties. For example, a nursing care plan in an Australian residential aged care home may be structured with several sections under each care domain such as pain, mobility, lifestyle, nutrition and continence. The information is recorded in free-text style, and various terms are used singly or in combination to name each of the four sections in the formats that are used by a facility during a particular period (Figure 3).
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| [[File:Figure 2-2. A sample nursing assessment form for an Australian residential aged care home..png|thumb|Figure 2-2. A sample nursing assessment form for an Australian residential aged care home]]
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| [[File:Figure 3-3. An example of a nursing care plan in an Australian residential aged care home..png|thumb|Figure 3-3. An example of a nursing care plan in an Australian residential aged care home]]
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| === Progress notes ===
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| A [[progress note]] is the record of nursing actions and observations in the nursing care process.<ref>"UW Internal Medicine Residency Program". Retrieved 2009-04-10</ref> It helps nurses to monitor and control the course of nursing care.
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| [[File:Figure 3-1. An example of a nursing care plan in an Australian residential aged care home..png|thumb|Figure 3-1. An example of a nursing care plan in an Australian residential aged care home.]]
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| Generally, nurses record information with a common format. Nurses are likely to record details about a client's clinical status or achievements during the course of the nursing care.
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| [[File:Figure 4. A sample progress note in an Australian residential aged care home..png|thumb|Figure 4. A sample progress note in an Australian residential aged care home.]]
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| == Recording format ==
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| === Paper-based nursing documentation ===
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| The paper-based nursing documentation has been in place for decades. Client's data are recorded in paper documents. The information in these documents needs to be integrated for sense-making in a nursing decision.
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| === Electronic nursing documentation ===
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| Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. [[Electronic health record|Electronic nursing documentation systems]] have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving communication and care service delivery.<ref>Zhang Y, Yu P, Shen J. The benefits of introducing electronic health records in residential aged care facilities:A multiple case study. Interna- tional Journal of Medical Informatics 2012; 81: 690–704.</ref>
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| === Comparison of the quality of paper-based and electronic documentation ===
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| Electronic nursing documentation systems are able to produce somewhat better quality data in comparison with paper-based systems, in certain respects depending on the characteristics of the systems and the practice of the various study settings. The common benefits of electronic documentation systems include the improvement of comprehensiveness in documenting the nursing process, the use of standardized language and the recording of specific items about particular client issues and relevance of the message. In addition, electronic systems can improve legibility, dating and signing in nursing records.
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| For the documentation of nursing assessment, the electronic systems significantly increased the quantity and comprehensiveness of documented assessment forms in each record. In regard to the NCP, the electronic standardized NCPs were graded with a higher total quality score than its paper-based counterpart. In addition, in comparison with the paper-based documentation systems, the electronic systems, due to their automatic functions, were able to improve the format, structure and process features of documentation quality such as legibility, signing, dating, crossing out error and space with a single line and resident identification on every page.
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| Paper-based documentation has been found to be inferior in comparison with electronic documentation. This is caused by the inherent nature of paper being difficult to update, time-consuming in a recording. Thus, the records are often incomplete, illegible, repetitive and missing signatures.<ref>Ammenwerth E,Eichstadter R,Haux R et al.A randomized evaluation of a computer-based nursing documentation system. Method Inform Med 2001; 40: 61–68.</ref>
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| [[File:Figure 3-2. An example of a nursing care plan in an Australian residential aged care home..png|thumb|Figure 3-2. An example of a nursing care plan in an Australian residential aged care home]] | |
| Electronic nursing documentation systems have the potential to improve the quality of documentation structure and format, process and content in comparison with paper-based documentation, as demonstrated in a comparative study of electronic and paper-based nursing admission forms.<ref name=":0"> Wang, N., Yu, P., & Hailey, D. (2012). Description and comparison of quality of electronic versus paper-based resident admission forms in Australian aged care facilities. International Journal of Medical Informatics, doi:10.1016/j.ijmedinf.2012.11.011</ref> However, improvement in documentation quality is not necessarily to be brought about by the introduction of electronic nursing documentation system to replace paper-based documentation. For example, Wang et al.<ref name=":0" /> that although the electronic nursing assessment form contained more documented assessment forms, which covered a wider range of resident care needs, they did not perform better than the previous [null paper-based assessment forms according to] the quality criteria of [null completeness] and timeliness. Therefore, further work on the usage of the electronic documentation systems may focus on improving form design and usage. There is also a need for improvement in compliance with standards in order to better meet the clients' care needs.
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| == Quality of nursing documentation ==
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| A study by the National Client Safety Agency (NPSA)<ref>National Clients Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospital clients. NPSA, London. <nowiki>http://tinyurl.com/yk8ao5x</nowiki> (Accessed 20 November 2011)</ref> found that poor standards of documentation were a contributory factor in the failure to detect clients who were clinically deteriorating. Nurses are responsible for maintaining accurate records of the care they provide and are accountable if information is incomplete and inaccurate.<ref>Owen K (2005) Documentation in nursing practice. Nurs Stand 19(32): 48–9</ref> Thus, a quality standard is required for recording of nursing documentation.
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| The systematic review of nursing documentation audit studies in different settings<ref>Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: A mixed-method systematic review.Journal of Advanced Nursing 2011; 67: 1858–1875.</ref> identified the following relevant quality characteristics of nursing documentation:
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| * Quality of documentation structure and format: relates to constructive features and physical presentation of records such as quantity, completeness, legibility, read- ability, redundancy and the use of abbreviations.
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| * Quality of documentation process: the procedural issues of capturing client data such as nurse's signature and designation, date, chronological order, timeliness, regularity of documentation and concordance between documentation and reality.
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| * Quality of documentation content: refers to the message from data about a care process. It is concerned with the comprehensiveness, appropriateness and the relation- ship of the five steps of the nursing process. The care issue recorded at each step is also considered.
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| == Standardized nursing terminology ==
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| [[NANDA|North American Nursing Diagnosis Association (NANDA)]] nursing diagnosis:
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| NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses standardized nursing terminology that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses.
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| [[Nursing Interventions Classification|Nursing intervention classification (NIC)]]:
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| The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan.
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| [[Nursing Outcomes Classification|Nursing outcome classification (NOC)]]:
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| The Nursing Outcomes Classification (NOC) is a classification system which describes client outcomes sensitive to nursing intervention.
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| The [[Omaha System]]:
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| The Omaha System is a standardized health care terminology consisting of an assessment component (Problem Classification Scheme), a care plan/services component (Intervention Scheme), and an evaluation component (Problem Rating Scale for Outcomes).
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| International Classification for Nursing Practice (ICNP):
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| The International Classification for Nursing Practice (ICNP) is a collaborative project under the auspices of the International Council of Nurses. The ICNP provides a structured and defined vocabulary as well as a classification for nursing and a framework into which existing vocabularies and classifications can be cross-mapped to enable comparison of nursing data.<ref>Wake, M., & Coenen, A. (1998). Nursing diagnosis in the international classification for nursing practice (icnp). ''International Journal of Nursing Knowledge,'' ''5''(4), 335.</ref>
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| == Structured documentation ==
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| Structured documentation takes the form of pre-printed guidelines for specific aspects of care and can, therefore, focus nursing care upon diagnoses, treatment aims, client outcomes and evaluations of care.<ref>Dahm M, Wadensten B (2008) Nurses' experiences of and opinions about using standardised care plans in electronic health records; a questionnaire study. J Clin Nurs 17(16): 2137–45</ref> It can improve client care by replacing the practice of vague, narrative style entries by nurses with cohesive and accurate information determined by the format of the care plan.<ref> Irvine K, Tracey M, Scott A, Hyde A, Butler M, MacNeela P (2006) Discursive practices in the documentation of client assessments. Journal of Advanced Nursing 53(2): 151–9</ref> The clarity of the recorded information also facilitates clinical auditing and evaluation of documentation practices through.<ref>Saranto K, Kinnunen U (2009) Evaluating nursing documentation-research designs and methods: systematic review. J Adv Nurs 65(3): 464–76</ref> Therefore, the introduction of structured documentation and care plans are seen as a means by which nurses can raise standards of record-keeping practice.<ref>Law L, Akroyd K, Burke L (2010) Improving nursing documentation and record-keeping in stoma care. Br J Nurs 19(21): 1328–32</ref>
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| == References ==
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| <references />{{Nursing|nursing documentation=}}
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| [[Category:Nursing]] | | [[Category:Nursing]] |
| [[Category:Nursing informatics]] | | [[Category:Healthcare]] |
| [[Category:Data collection]]
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| [[Category:Documents]]
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| {{dictionary-stub1}}
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