Nursing documentation for communicating and evaluating care

Abstract

Aims: To investigate the utility of electronic nursing documentation by exploring to what extent and for what purpose general practitioners use nursing documentation and to what extent and in which cases care unit managers use nursing documentation for quality development of care.

Background: As health care includes multidisciplinary activities, communication about the care given is essential. To assure delivery of good and safe care, quality development is necessary. The main tool available for communication and quality development is the patient record. In many studies, nursing documentation has been found to be inadequate for this purpose.

Design: This study had a cross-sectional descriptive design.

Methods: Data were collected by postal questionnaires, one to the general practitioners (n = 544) and one to care unit managers (n = 82) in primary health care. Data were analysed by descriptive statistical and qualitative content analysis.

Results: The general practitioners usually used the nursing record as the foremost source of information for treatment follow-up. The results, however, point out weaknesses and shortcomings in the nursing records, such as difficulties in finding important information because of a huge amount of routine notes. The care unit managers generally (74%) used the record for statistical purposes, while only half of them used it to evaluate care.

Conclusion: Nursing records need more clarity and need to be more prominent regarding specific nursing information to fulfil their purpose of transferring information and to constitute a base for quality development of care.

Relevance to clinical practice: The results of this study can provide a part of a basis upon which a multi-professional patient record could be developed and which could also function as an alarm to managers at different levels to prioritize the development of nursing documentation.