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