Background: Documentation enhances patient safety and continuity. According to national Danish guidelines, nursing documentation should contain core areas such as: nutritional status, pain, sleep, urinary- and bowel elimination, skin and tissue, cognitive and psychosocial factors. Documentation practice and its association to patient impairments have not been examined as a comprehensive, combined set of nursing core areas in acutely admitted older medical patients. Therefor the objective of this study was to examine levels of nursing documentation and the associations between documentation levels and patient impairments.
Methods: A descriptive study of acutely admitted patients above 65 years old. Audit of handwritten nursing records and structured patient interviews were conducted to assess eight core areas based on the national Danish guidelines for nursing documentation: nutritional status, pain, sleep, urinary- and bowel elimination, skin and tissue, cognitive and psychosocial factors. Furthermore measures of Charlson Comorbidity Index (CCI) and self-reported health were collected.
Results: 90 acutely admitted medical patients ≥ 65 years were enrolled. The prevalence of documentation was between 4 and 80%. We found a higher prevalence of unstructured documentation. Looking at six of the eight core areas, 33% of the patients had 0-2 areas documented. For all the eight core areas we found no difference in the prevalence of documentation for patients with impairment compared to patients without impairment, nor did we find a significant association between patient documentation and age, sex, CCI, or self-rated health.
Conclusions: The results implies that something else than national guidelines, patient impairments, age, sex, CCI and self-rated health of the patient are determining whether documentation is done or not.