Nursing Documentation: Frameworks and Barriers

Article excerpt

The quality of nursing documentation is an important issue for nurses both nationally and internationally. Nursing documentation should, but often does not show the rational and critical thinking behind clinical decisions and interventions, while providing written evidence of the progress of the patient. A number of frameworks are currently available to assist with nursing documentation including narrative charting, problem orientated approaches, clinical pathways, and focus notes. However many nurses still experience barriers to maintaining accurate and legally prudent documentation.

A review of nursing documentation of patient care and progress towards achieving outcome goals in our organisation identified a lack of clear and easy to follow information about the patient's progress. In order to address with this issue a project group was established to look at different frameworks for nursing documentation. The aim of the project was to identify and implement a documentation framework that would encourage critical thinking and provide evidence of the rationale for nursing actions utilising a problem based approach in order to provide accurate evidence of patient progress. This paper provides a synopsis of available literature related to the frameworks mentioned above, highlights barriers to safe, timely and accurate documentation for nurses, and concludes with an explanation of the framework chosen as a result of this review.

Keywords: nursing documentation; nursing reports; literature review; progress notes

The quality of nursing documentation is an important issue for nurses both nationally and internationally. It is clear from many cases on the New Zealand Health and Disability Commissioner Website (Health and Disability Commissioner, 2009) that issues related to poor nursing documentation need to be urgently addressed. Different nursing documentation methods such as SOAPIE are used to provide frameworks that guide nursing documentation. However these methods do not necessarily meet the documentation needs of busy clinical areas in the current health environment because they focus on single problem entries and patients are often complex with multiple problems.

Nursing documentation in our organisation has lacked a clear rationale for clinical decisions and evidence of critical thinking. In order to deal with this issue a project group was established to look at different methods of nursing documentation. The aim of this project was to identify a method that would encourage critical thinking by using a problem based approach. This article provides a summary of the literature reviewed at the commencement of this project and a summary of the framework chosen as a result of this review.

The review of literature sought to identify current methods of nursing documentation in order to identify any that could be used to improve the quality of nursing progress notes. A literature search was performed using CINAHL and MEDLINE. Key words used included the following; documentation, progress notes, and nursing reports. The review focused on documentation methods, problem orientated documentation, barriers to documentation, risk management, and legal implications. Literature published between 1998 and 2011 was reviewed. Some seminal pieces of literature have been included from 1974 to 1997 as these provide relevant background information. Much of the more recent literature available is in the form of systematic reviews with a focus on electronic documentation (Kelly, Brandon, & Dicherty, 2011), audit instruments (Wang, Hailey, & Yu, 2011), and accuracy of documentation (Paans, Nieweg, Van der Schans, & Sermeus, 2011) which have not been discussed in this paper.

Much of the available literature accessed was related to nursing documentation within acute care settings and originated from Europe (Darmer et al., 2006; Ehrenberg & Birgersson, 2003; Ehrenberg, Ehnfors, & Thorell-Ekstrand, 1996; Hellesø & Ruland, 2001; Idvall & Ehrenberg, 2002) with a focus on electronic documentation (Gjevjon & Hellesø, 2010; Häyrinen & Saranto, 2009; Kelly et al. …