Assessment of quality in psychiatric nursing documentation – a clinical audit

BMC Nursing

Birgitte Graverholt¹  Birgitte Espehaug¹  Katrine Aasekjær¹  Marit Helen Instefjord² 

[1] Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway;Helse More og Romsdal Health Trust, Ålesund, Norway

关键词: Psychiatric nursing;    Nursing process;    Nursing documentation;    Evidence-based nursing;    Clinical audit;   

Others  :  1090782
DOI  :  10.1186/1472-6955-13-32

 received in 2013-11-21, accepted in 2014-10-03,  发布年份 2014

【 摘 要 】

Background

Quality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written nursing documentation in a psychiatric hospital.

Method

A cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument. In 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to December 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes, nursing care plans, progress and outcome reports, discharge notes and information about the patients’ personal details. The items of N-Catch were scored for quantity and/or quality (0–3 points).

Results

The item ‘quantity of progress and evaluation notes’ had the lowest score: in 86% of the records progress and outcome were evaluated only sporadically. The items ‘the patients’ personal details’ and ‘quantity of record structure’ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these items.

Conclusions

Deficiencies in nursing documentation identified in other clinical specialties also apply to the clinical field of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs improvements to ensure continuity and patient safety. This study shows the importance of the existence of a validated tool, readily available to assess local levels of nursing documentation quality.

【 授权许可】

   
2014 Instefjord et al.; licensee BioMed Central Ltd.

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