Poor record keeping in nursing

Running head: ERRORS IN HOME CARE NURSING DOCUMENTATION 1

ERRORS IN HOME CARE NURSING DOCUMENTATION 9

Errors in Home Care Nursing Documentation

Cheryl Kyles

Troy University

Errors in Nursing Documentation

Introduction

Nursing documentation forms an integral part of the professional nursing practice. In the last few decades, the nursing profession has witnessed a change in the way documentation should be handled with countries all over the world adopting more sophisticated record-keeping systems. New systems have been designed, old ones re-evaluated and the nurses’ level of compliance with the legal framework monitored. Home health care involves a variety of healthcare services that are administered at home for ill or injured patients. In developed countries, home care is just as efficient as the care received in a skilled nursing facility, and it is relatively cheaper. Home, health care professionals, offer services such as wound care, patient education, therapy whether intravenous or nutritional, administer injections according to the treatment plan and monitor the progress of seriously ill and unstable patients. As home health care professionals, we ensure our patients get better, ensure they become more dependent and self-sufficient.

Documentation in the nursing profession encompasses a wide range of issues and topics. Recordkeeping is perceived as an important element that enables practitioners, home care nurses and other health professionals to continue offering quality care, enhance patient safety and comply with the set recordkeeping guidelines. Proper documentation should be factual, up to date and comprehensive to ensure consistency in the various assessments conducted, healthcare provided, and a detailed evaluation of how the patient is responding to care (Keenan, Yakel, Tschannen, & Mandeville, 2008). According to Scruth (2014), modern documentation systems are designed to ensure continuous and quality patient care as legally required. Accurate and complete clinical records serve as a reliable source that aids communication, enhances research and assists the policymakers in designing a suitable legal framework. Inaccurate and incomplete documentation, on the other hand, fails to provide the necessary foundation for quality care provision, improvement and effective decision making regarding resource allocation (Obioma, 2017).

Hypothesis

Errors in documentation can impede evaluation of the nursing care provided since it is incomprehensive and incomplete thus leading to poor patient outcomes, liability issues for the caregiver, and unnecessary health care costs to the patient. Poor documentation also prevents the health care provider from noticing when a patient’s condition worsens hence causing adverse events in health care.

Problem Statement

Home health care providers have to contend with heavy workloads in the modern world ranging from managing patient electronic health records, poor working conditions, difficult patients to lengthy and exhausting shifts. Documentation errors in home-based patients can also be contributed by poor environmental conditions, inadequate training, infrastructural challenges and lack of communication among other factors. The documentation procedures taught during initial training are usually inadequate since they contain un-updated information regarding documentation. Poor documentation hinders effective communication of the health status of the patient with other health care professionals leading to wrong decision making and poor patient outcomes.

Purpose of the Paper

The purpose of this research paper is to provide insights into documentation issues in the nursing profession, especially for home health care providers. The study will highlight the common documentation errors in nursing and how health care professionals can avoid and handle them. The paper analyses information from the various literature on documentation in nursing and is meant to enhance home care nurses’ knowledge and competence in matters pertaining to effective documentation of patient care. The paper is aimed at improving the nurses’ documentation skills and fill the knowledge gap left by previous research on the topic.

Theoretical Framework

Florence Nightingale is considered the mother of Nursing since she developed the first nursing theory. Florence’s theory focused on manipulating the patient’s surroundings to give the most comfortable recovery environments. The interpersonal model was introduced by Hildegard Peplau which perceives the interpersonal process as trying to develop a nurse-patient relationship. On her part, Ida Jean Orlando developed the three nursing elements that comprise a nursing situation; the elements include client behaviour, the nurse reaction and action. Other notable theorists introduced different concepts and models. For instance, the adaptation model by Sister Callista Roy views a human being as a unified bio-psychosocial system that requires constant interaction as environments change. According to the model, the goal of nursing is to assist the patient to adapt to his physiological needs during ill health (Fawcett, 1984).

Conceptual Framework

The nursing process model is an internationally accepted concept which dates back to the general systems theory and which formed a basis of scientific inquiry in the mid-20th century. Orlando (1961) was the first to describe the nursing process model through her problem-solving approach to nursing practice and documentation. The nursing process model was initially a four-step process that involved assessment, planning, implementation and evaluation. The fifth step, nursing diagnoses was added in a later version of the model, and the five-step approach is accepted to date. According to Meleis (1997), the nursing process model is the centrally accepted concept for both the nursing practice and documentation. The model is considered as the process where the caregiver and the patient interact and where the caregiver gets to understand the patient’s needs. The VIPS model is another commonly used model. Researchers argue that the VIPS model enhances a nurse’s understanding of the nursing process model (Meleis, 2011).

Literature Review and Synthesis

Previous studies have identified barriers to proper documentation and the source of errors in documenting patient records. According to Bjorvell (2002), most nurses perceive barriers to documentation as lacking adequate charting system, tight schedules, lack of value and inability to use correct phrasing. In another study where 14 registered nurses (RNs) were interviewed, reasons for errors in the documentation included overwhelming administration forms, insufficient time to document, inadequate knowledge regarding the practice and lack of a standardized nursing terminology. Among barriers identified by Bjorvell included an unwillingness to accept change, inability to understand the importance of documentation, inconsistent routines and schedules, unsupportive leadership and difficulties in recording (Wang, Björvell, Hailey & Yu, 2013).

Scholars have been attempting to enhance documentation in nursing by exploring and describing the methods of improving comprehensiveness in the documentation. Research in the area has been emphasized since documentation is an area of priority and forms an integral part of nursing practice. Most of the past studies have however been carried in a hospital setting. The few studies that focused on community health explored the overall comprehensiveness of nursing documentation in a home health care. According to Gjevjon & Helleso (2010), more studies need to be directed towards documentation errors in community settings since home-based care differs significantly from facility-based nursing. Previous research was conducted using paper-based medical records, but currently, most of the home health based patients are now electronic (Wang, Björvell, Hailey & Yu, 2013).

Nursing documentation has amassed significant interest among scholars and practitioners who have been putting efforts to its quality. Hughes (2008) argues that recent interventions in the field are as a result of deficits noted in home health record keeping. A recent study by Gershater et al. (2010) showed that there was insufficient documentation in home nursing. The inadequacy has led to a myriad of both professional and economic consequences. To reduce documentation errors, researchers suggest that educational training programs for healthcare professionals be introduced. Another study by Saranto & Kinnunen, (2009) involved an assessment of change in nurses’ behaviour especially regarding documentation practices after undertaking the educational and training programs. The study identified several documentation errors emphasizing the need for the introduction of such programs in the nursing profession (Wang, Hailey & Yu, 2011).

In a study by Urquhart and Currell, (2004) which compared variations in nursing record systems and their effect on the profession and the patient outcomes, it concluded that health caregivers experienced tension between the patient’s needs and the hospital’s heavily structured documentation system. In another literature review by Langowski where he compared the quality of health care and electronic health record (EHR). The study indicated that the quality of documentation improved with EHR (Green &Thomas, 2008). According to the American Nursing Association, some of the common nursing documentation errors include; failure to fill in the date, time and the signature of an entry. Another error arises when the nurse's handwriting is sloppy or illegible which results in communication problems and confusion. Undocumented or omitted medications or treatments is another common error which might cost a patient their lives or a nurse her job. Omitted medications must be explained and signed against to avoid confusion. This should apply to medical charts or forms which have blank spaces left. Other common documentation errors include adding late entries, using inappropriate abbreviations and entering information in the wrong chart among others (American Nurses Association, 2010).

Conclusion and Recommendations

The study supports our hypothesis. Effective nursing documentation especially a system that focuses on the relevant health care aspects does actually result in better patient outcomes. The study also finds proper documentation as an aspect that enhances communication with colleagues and other healthcare professionals. Literature review reveals that errors in nursing documentation can be reduced through the introduction of educational and training programs to home health caregivers. Most of the studies that compared the documentation systems and patient's outcomes revealed that training caregivers to use the structured documentation system enhances their record keeping and patient care planning skills. Training, however, must be used alongside other methods since the nursing profession is broad and covers a wide range of issues. The study also revealed the little amount of research on improving record keeping in home health care settings.

To bridge the knowledge deficiency in the nursing documentation issues especially in home healthcare settings, future research needs to focus on the topic so as to suggest ways in which we can improve the situation. New knowledge acquired through the different studies should be disseminated to the nursing professionals through training and educational programs since they have been found to address the information deficits. Both the VIPS and the nursing process models structures have been found to home health care alongside other minimum standards of nursing documentation. However, I would not recommend it in other settings since it is non-flexible in terms of documentation structure. Documentation in a home health care setting should include observations and regular assessments which indicate the patient progress and aid decision making.

References

American Nurses Association. (2010). Nursing's social policy statement: The essence of the profession. Nursesbooks. org.

Fawcett, J. (1984). Analysis and evaluation of conceptual models of nursing.

Green, S. D., & Thomas, J. D. (2008). Interdisciplinary collaboration and the electronic medical record. Pediatric nursing, 34(3), 225.

Keenan, G. M., Yakel, E., Tschannen, D., & Mandeville, M. (2008). Documentation and the nurse care planning process.

Meleis, A. I. (2011). Theoretical nursing: Development and progress. Lippincott Williams & Wilkins.

Obioma, C. (2017). Improving the Quality of Nursing Documentation in Home Health Care Setting (Doctoral dissertation, Walden University).

Wang, N., Björvell, C., Hailey, D., & Yu, P. (2013). Development of the Quality of Australian Nursing Documentation in Aged Care (QANDAC) instrument to assess paper-based and electronic resident records. Australasian Journal On Ageing, 33(4), E18-E24. http://dx.doi.org/10.1111/ajag.12072

Wang, N., Hailey, D., & Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: a mixed‐method systematic review. Journal of Advanced Nursing, 67(9), 1858-1875.