‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care?

Charalambous, Liz; Goldberg, Sarah

Abstract

Introduction: Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment process which can improve older patient’s outcomes following a hospital admission.
Aims: to understand older person nurses experiences of and attitudes to documentation.
Methodology: Semi-structured, in depth interviews of eight qualified nurses at an acute hospital trust. Interviews were analysed using the framework approach to identify key themes.
Results: three overarching themes were identified: gaps, mishaps and overlaps. Gaps refer to information which was missing, inaccurate or inconsistent; mishaps refer to the consequences of these inaccuracies and inconsistencies and overlaps refer to the problem of duplications in recording of information.
Discussion: Older person nurses report many inconsistencies, omissions and duplications in their documentation. This has implications for how nursing contributes to the comprehensive geriatric assessment and the quality of care of older patients.
Recommendations for practice: New ways must be found to minimise and streamline existing documentation to ensure that records are complete, timely and person-centred. Nurses should be mindful that emerging digital technology systems do not create further problems. Ward nurses need to take greater control of development of documentation.

Citation

Charalambous, L., & Goldberg, S. (2016). ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care?. Journal of Research in Nursing, 21(8), 638-648. https://doi.org/10.1177/1744987116678900

• Journal Article Type: Article
• Acceptance Date: Sep 24, 2016
• Online Publication Date: Dec 20, 2016
• Publication Date: Dec 20, 2016
• Deposit Date: Oct 27, 2016
• Publicly Available Date: Dec 20, 2016
• Journal: Journal of Research in Nursing
• Print ISSN: 1744-9871
• Electronic ISSN: 1744-988X
• Publisher: SAGE Publications
• Peer Reviewed: Peer Reviewed
• Volume: 21
• Issue: 8
• Pages: 638-648
• DOI: https://doi.org/10.1177/1744987116678900
• Keywords: Gerontology, Older people, Nurses as subjects, Qualitative, Communication, nursing documentation, frailty, geriatric nurse,comprehensive geriatric assessment, Audit
• Public URL: https://nottingham-repository.worktribe.com/output/832745
• Publisher URL: http://journals.sagepub.com/doi/10.1177/1744987116678900