Nursing documentation

Last updated

Nursing documentation is the record of nursing care that is planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a qualified nurse. 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, care nurses' knowledge of nursing documentation, and is 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.

Contents

Purposes

Documentation of the nursing process

The internationally accepted nursing process consists of five steps: assessment, nursing problem/diagnosis, goal, intervention and evaluation. [1] 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.

Content

Nursing documentation mainly consists of a client's background information or nursing history referred as admission form, numerous assessment forms, nursing care plan and progress notes. These documents record the client's data captured at the relevant stages of the nursing process. [2] 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.

Admission

An 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. [3] The form is completed by a nurse when a client is admitted to a health care facility.

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, past medical history, history of present illness, and allergies in nursing

Assessment

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. [4]

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. [5] Complete and accurate nursing assessment determines the accuracy of the other stages of the nursing process. [6]

The nursing documents may contain a number of assessment forms. In an assessment form, a licensed 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. [7]

Nursing care plan

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. [6] It was originally developed in hospitals to guide nursing students or junior nurses in providing care to client; however, the format was task-oriened rather than nursing-process-based. [8] Nowadays, the NCP is widely used in nursing in various clinical and educational settings as a tool to direct individualized nursing care for clients. [9] [10] [11] [12]

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

Progress notes

A progress note is the record of nursing actions and observations in the nursing care process. [13] It helps nurses to monitor and control the course of nursing care.

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.

Recording format

Paper-based nursing documentation

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.

Electronic nursing documentation

Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. 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. [14]

Comparison of the quality of paper-based and electronic documentation

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.

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.

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. [15]

Figure 3-2. An example of a nursing care plan in an Australian residential aged care home Figure 3-2. An example of a nursing care plan in an Australian residential aged care home..png
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. [16] 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. [16] 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.

Quality of nursing documentation

A study by the National Client Safety Agency (NPSA) [17] 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. [18] Thus, a quality standard is required for recording of nursing documentation.

The systematic review of nursing documentation audit studies in different settings [19] identified the following relevant quality characteristics of nursing documentation:

Standardized nursing terminology

North American Nursing Diagnosis Association (NANDA) nursing diagnosis:

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.

Nursing intervention classification (NIC):

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.

Nursing outcome classification (NOC):

The Nursing Outcomes Classification (NOC) is a classification system which describes client outcomes sensitive to nursing intervention.

The Omaha System:

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).

International Classification for Nursing Practice (ICNP):

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. [20]

Structured documentation

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. [21] 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. [22]   The clarity of the recorded information also facilitates clinical auditing and evaluation of documentation practices through. [23] Therefore, the introduction of structured documentation and care plans are seen as a means by which nurses can raise standards of record-keeping practice. [24]

Related Research Articles

<span class="mw-page-title-main">Health informatics</span> Computational approaches to health care

Health informatics is the field of science and engineering that aims at developing methods and technologies for the acquisition, processing, and study of patient data, which can come from different sources and modalities, such as electronic health records, diagnostic test results, medical scans. The health domain provides an extremely wide variety of problems that can be tackled using computational techniques.

A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice compared to dependent interventions driven by physician's orders. Nursing diagnoses are developed based on data obtained during the nursing assessment. A problem-based nursing diagnosis presents a problem response present at time of assessment. Risk diagnoses represent vulnerabilities to potential problems, and health promotion diagnoses identify areas which can be enhanced to improve health. Whereas a medical diagnosis identifies a disorder, a nursing diagnosis identifies the unique ways in which individuals respond to health or life processes or crises. The nursing diagnostic process is unique among others. A nursing diagnosis integrates patient involvement, when possible, throughout the process. NANDA International (NANDA-I) is body of professionals that develops, researches and refines an official taxonomy of nursing diagnosis.

A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:

<span class="mw-page-title-main">Nursing process</span>

The nursing process is a modified scientific method. Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. It should not be confused with nursing theories or health informatics. The diagnosis phase was added later.

The SOAP note is a method of documentation employed by healthcare providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. Additionally, it serves as a general cognitive framework for physicians to follow as they assess their patients.

Nursing assessment is the gathering of information about a patient's physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG's may be delegated to certified nurses aides or nursing techs. It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or mental health. Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions. An assessment format may already be in place to be used at specific facilities and in specific circumstances.

A nursing care plan provides direction on the type of nursing care the individual/family/community may need. The main focus of a nursing care plan is to facilitate standardised, evidence-based and holistic care. Nursing care plans have been used for quite a number of years for human purposes and are now also getting used in the veterinary profession. A care plan includes the following components: assessment, diagnosis, expected outcomes, interventions, rationale and evaluation.

In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes. Both diagnosis and intervention codes are assigned by a health professional trained in medical classification such as a clinical coder or Health Information Manager.

Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit medical research organization. LOINC was created in response to the demand for an electronic clinical care and management database and is publicly available at no cost.

A clinical nurse specialist (CNS) is an advanced practice nurse who can provide advice related to specific conditions or treatment pathways. According to the International Council of Nurses (ICN), an Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. Clinical Nurse Specialists are registered nurses who have had graduate level nursing preparation at the master's or doctoral level as a CNS. They are clinical experts in evidence-based nursing practice within a specialty area, treating and managing the health concerns of patients and populations. The CNS specialty may be focused on individuals, populations, settings, type of care, type of problem, or diagnostic systems subspecialty. CNSs practice autonomously and integrate knowledge of disease and medical treatments into the assessment, diagnosis, and treatment of patients' illnesses. These nurses design, implement, and evaluate both patient–specific and population-based programs of care. CNSs provide leadership in the advanced practice of nursing to achieve quality and cost-effective patient outcomes as well as provide leadership of multidisciplinary groups in designing and implementing innovative alternative solutions that address system problems and/or patient care issues. In many jurisdictions, CNSs, as direct care providers, perform comprehensive health assessments, develop differential diagnoses, and may have prescriptive authority. Prescriptive authority allows them to provide pharmacologic and nonpharmacologic treatments and order diagnostic and laboratory tests in addressing and managing specialty health problems of patients and populations. CNSs serve as patient advocates, consultants, and researchers in various settings.

Health information management (HIM) is information management applied to health and health care. It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespread computerization of health records, traditional (paper-based) records are being replaced with electronic health records (EHRs). The tools of health informatics and health information technology are continually improving to bring greater efficiency to information management in the health care sector.

MEDCIN, a system of standardized medical terminology, is a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 38 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED CT, CPT, ICD-9-CM/ICD-10-CM, DSM, LOINC, CDT, CVX, and the Clinical Care Classification (CCC) System for nursing and allied health.

Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress notes are written in a variety of formats and detail, depending on the clinical situation at hand and the information the clinician wishes to record. One example is the SOAP note, where the note is organized into Subjective, Objective, Assessment, and Plan sections. Another example is the DART system, organized into Description, Assessment, Response, and Treatment. Documentation of care and treatment is an extremely important part of the treatment process. Progress notes are written by both physicians and nurses to document patient care on a regular interval during a patient's hospitalization.

Evidence-based nursing (EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. This approach is using evidence-based practice (EBP) as a foundation. EBN implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. The goal of EBN is to improve the health and safety of patients while also providing care in a cost-effective manner to improve the outcomes for both the patient and the healthcare system. EBN is a process founded on the collection, interpretation, appraisal, and integration of valid, clinically significant, and applicable research. The evidence used to change practice or make a clinical decision can be separated into seven levels of evidence that differ in type of study and level of quality. To properly implement EBN, the knowledge of the nurse, the patient's preferences, and multiple studies of evidence must all be collaborated and utilized in order to produce an appropriate solution to the task at hand. These skills are taught in modern nursing education and also as a part of professional training.

The Omaha System is a standardized health care terminology consisting of an assessment component, a care plan/services component, and an evaluation component. Approximately 22,000 health care practitioners, educators, and researchers use Omaha System to improve clinical practice, structure documentation, and analyze secondary data. Omaha System users from Canada, China, The Czech Republic, Estonia, Hong Kong, Japan, Mexico, New Zealand, The Netherlands, Turkey, the United States, and Wales, have presented at Omaha System International Conferences.

Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. A discipline-specific process may be referenced accordingly.

The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.

Clinical point of care (POC) is the point in time when clinicians deliver healthcare products and services to patients at the time of care.

Genetics nursing is a nursing specialty that focuses on providing genetic healthcare to patients.

Clinical documentation improvement (CDI), also known as "clinical documentation integrity", is the best practices, processes, technology, people, and joint effort between providers and billers that advocates the completeness, precision, and validity of provider documentation inherent to transaction code sets sanctioned by the Health Insurance Portability and Accountability Act in the United States.

References

  1. ↑ 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.
  2. ↑ Blair, W., & Smith, B. (n.d). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 41(2), 160-168.
  3. ↑  "General Info". Archived from the original on 12 March 2009. Retrieved 2009-04-03
  4. ↑ Oroviogoicoechea C., Elliott B. & Watson S. (2008) Review: evaluating information systems in nursing. Journal of Clinical Nursing 17, 567–575.
  5. ↑ Crisp J., Taylor C., Potter PA. & Perry A.G. (2005) POTTER and PERRY'S fundamentals of nursing (2nd ed). Elsevier Australia.
  6. 1 2 White L. (2002) Documentation and the Nursing Process. Delmar Learning, Clifton Park, NY
  7. ↑  L. White, Documentation and the Nursing Process, Delmar Learning, Clifton Park, NY, 2002.
  8. ↑ Greenwood D. (1996) Nursing care plans: issues and solutions. Nursing Management 27(3), 33-40.
  9. ↑ 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 Daly J.M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23. 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. 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.
  10. ↑ Daly J.M., Buckwalter K. & Maas M. (2002) Written and computerized care plans. Journal of Gerontological Nursing 28(9), 14–23.
  11. ↑ 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.
  12. ↑ 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.
  13. ↑ "UW Internal Medicine Residency Program". Retrieved 2009-04-10
  14. ↑ 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.
  15. ↑ 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.
  16. 1 2  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
  17. ↑ National Clients Safety Agency (2007) Recognising and responding appropriately to early signs of deterioration in hospital clients. NPSA, London.
  18. ↑ Owen K (2005) Documentation in nursing practice. Nurse Stand 19(32): 48–9
  19. ↑ 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.
  20. ↑ Wake, M., & Coenen, A. (1998). Nursing diagnosis in the international classification for nursing practice (icnp). International Journal of Nursing Knowledge, 5(4), 335.
  21. ↑ 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
  22. ↑  Irvine K, Tracey M, Scott A, Hyde A, Butler M, MacNeela P (2006) Discursive practices in the documentation of client assessments. Journal of Advanced in Nursing 53(2): 151–9
  23. ↑ Saranto K, Kinnunen U (2009) Evaluating nursing documentation-research designs and methods: systematic review. J Adv Nurs 65(3): 464–76
  24. ↑ Law L, Akroyd K, Burke L (2010) Improving nursing documentation and record-keeping in stoma care. Br J Nurs 19(21): 1328–32
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.