Documenting patient risk and nursing interventions: record audit

Objective: The aim was to explore and compare documentation of the nursing process for patient safety in two nursing documentation systems: paper and digital records. Background: The ‘nursing process’ (assessment, planning, intervention, and evaluation) is recommended by professional nursing registration and health service accreditation bodies as a key component of understanding nurses’ clinical reasoning. Nurses’ responsibility for patient safety must be supported by comprehensive documentation practices. Study design and methods: A retrospective audit of twenty clinical care records (N = 20) randomly selected from a single acute medical ward at a tertiary hospital in Australia; ten from a digital trial that replicated selected paper forms and ten paper records as controls. The audit was conducted by two nurse researchers using a purpose built data extraction tool. Results: Patient age, gender and primary diagnoses were similar for the digital and paper care records. Documentation of the full nursing process was low in both record types, and comprehensiveness of nursing documentation was similar across the paper and digital records. Compared to the paper documents, the digital documents were more often rated as ‘complete’ (p<0.05). Documentation of risk to skin integrity (p<0.05) and evidence of completed nursing interventions to address risks were more frequent (p<0.05) in digital records. Discussion: The findings of this study highlight an important gap in comprehensive documentation of the nursing process that supports and informs the clinical reasoning of nurses for patient safety. Improvements in digital documents reflect future opportunity to enhance the quality of nurse documentation using technology specific strategies such as prompts, visualisation and nudge. Conclusion: This research identifies that both paper and digital systems of hospital documentation may fail to capture and communicate the clinical reasoning of nurses. Digital systems have the potential to improve capture of the clinical reasoning and nursing process. What is already known about the topic? Professional registration and healthcare accreditation bodies recommend nurses’ clinical decision making is underpinned by processes of assessment, planning, intervention and evaluation. Poor capture of nurses’ clinical decision making in their documentation has negative consequences for the continuity, quality and safety of care; including inadequate detection of deterioration and escalation of care. Electronic systems are expected to enhance capture of nurse decision making in documentation. What this paper adds: Nurses’ clinical reasoning was poorly captured in both paper and digital documentation systems. Nurses documented their intervention responses to identified patient risks more often in the digital system compared to paper records. Digital systems offer an opportunity to proactively nudge nurses towards improved documentation of nursing processes.