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The study of nursing documentation complexities

journal contribution
posted on 06.12.2017, 00:00 authored by A Cheevakasemsook, Ysanne ChapmanYsanne Chapman, K Francis, C Davies
This study aimed to explore complexities in nursing documentation and related factors. Nursing documentation has been one of the most important functions of nurses since the time of Florence Nightingale because it serves multiple and diverse purposes. Current health-care systems require that documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of quality of patient care. However, nursing documentation has not served such objectives because of its complexities. This study explores nursing documentation complexities and related factors through both qualitative and quantitative methodologies. The study used multiple methods of inquiry: in-depth interviewing; participant observation; nominal group processing; focus group meetings; time and motion study of nursing activities; and auditing of completeness of nursing documentation. Complexities in nursing documentation include three aspects: disruption, incompleteness and inappropriate charting. Related factors that influenced documentation comprised: limited nurses’ competence, motivation and confidence; ineffective nursing procedures; and inadequate nursing audit, supervision and staff development. These findings suggest that complexities in nursing documentation require extensive resolution and implicitly dictate strategies for nurse managers and nurses to take part in solving these complicated obstacles.

History

Volume

12

Issue

6

Start Page

366

End Page

374

Number of Pages

9

eISSN

1440-172X

ISSN

1322-7114

Location

Australia

Publisher

Wiley-Blackwell Publishing Asia

Language

en-aus

Peer Reviewed

Yes

Open Access

No

Era Eligible

Yes

Journal

International journal of nursing practice.