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Geriatr Nurs. 2017 Nov - Dec;38(6):578-583. doi: 10.1016/j.gerinurse.2017.04.007. Epub 2017 May 25.

Accuracy of documentation in the nursing care plan in long-term institutional care.

Author information

1
Hanze University of Applied Sciences Groningen, School of Nursing, Groningen, The Netherlands. Electronic address: a.tuinman@pl.hanze.nl.
2
University of Groningen and University Medical Center Groningen, Department Human Movement Sciences, Groningen, The Netherlands.
3
Hanze University of Applied Sciences Groningen, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands.
4
Hanze University of Applied Sciences Groningen, Research Group Nursing Diagnostics, Groningen, The Netherlands.
5
University of Groningen and University Medical Center Groningen, Department of Health Psychology, Groningen, The Netherlands.

Abstract

Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Inadequacies were especially found in the description of residents' care needs and stated nursing diagnoses as well as in progress and outcome reports. In somatic and psycho-geriatric units, higher accuracy scores were determined compared with residential care units. Investments in resources (e.g., time), reasoning skills of nursing staff, and implementation of professional standards in accordance with legal requirements may be needed to enhance the quality of nursing documentation.

KEYWORDS:

Care plan; Cross-sectional study; Long-term care; Nursing documentation; Nursing home; Nursing process

PMID:
28552204
DOI:
10.1016/j.gerinurse.2017.04.007
[Indexed for MEDLINE]

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