Documentation guidelines based on expectation of documentation helps accurate documentation among nurses in psychiatric settings

Mr. Sanjay K John¹, Prof. Chanu Bhattacharya²*

¹Staff Nurse, Sakra World Hospital, Bangalore

¹Professor, Father Muller Medical College Hospital, Mangalore

*Corresponding Author Email: chanu14@rediffmail.com

ABSTRACT:

Careful documentation is an integral part of nursing care. It is written information about a client that describes the care or service provided by nurse to client according to their need. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. In the present study an ‘ideal documentation guidelines of nurses caring mentally ill client’ was developed which can be used by the psychiatric nurses for thorough assessment as well as assessment of the documents. The ideal documentation guidelines consist of four important care areas namely are admission, discharge, selected procedure and specific incident. The study was conducted to compare the expectation of documentation by nurse administrators and actual performance by staff nurses in selected settings. Twenty five administrative nurses and 25 staff nurses were participated in the study. Result showed assessment of majority of actual performance documentation by the staff nurses showed almost proper behaviours and remaining was partially proper. No nurses documentations depict nurses behaviours improper (lowest level) or (highest level) i.e. proper. Same manner administrative nurse also expected a behaviour from the staff nurses that was almost proper behaviours in documentation. Study revealed actual performance with documentation and expectation of the administrators has a significant relationship. Training, CNE etc which might power to improve administrative nurses expectations of behaviours in psychiatric settings but an ideal documentation format or guideline can help nurses to follow proper documentation behaviour which will be based on the ideal documentation guidelines.

KEYWORDS: Nursing documentation, Nursing assessment, Nursing recording, Nursing information

INTRODUCTION:

Accurate record keeping and careful documentation is an essential part of nursing practice. The Nursing and Midwifery Council (NMC 2002) state that ‘good record keeping helps to protect the welfare of patients and clients’ – which of course is a fundamental aim for nurses’ everywhere¹. Documentation is any written information about a client that describes the care or service provided to that client. It is not merely a set of certain forms, framed and designed but a document of facts and figures; containing segments of observations by trained and experienced observers².

It is a perfect proof of the expertise and experience of the team work of all those contributing towards the patient's health. Without knowledge of care given in the past, and of circumstances which made that care necessary, continuity of care can't be achieved. The two main forms of communication in nursing are verbal handover reports and written nursing documents. It is seen that comprehensive nursing documentation improves patient care³.

A study was done to determine the underlying causes of persistent antipathy towards documentation in patient's chart. The results supported a common belief that resistance to charting is influenced by extrinsic or environmental factors, such as flexibility of charting systems and insufficient allocation of time. In addition, intrinsic factors of cognitive and psychosocial domain, such as lack of confidence about written expression, a tendency to succumb to group norms governing charting and difficulty in articulating the nature of nursing practice, surface as impediments to documentation⁴. Nurses are considered to be enhancers of healing and health. They use the humanistic ally oriented nursing practices to achieve their goal. In the care of mentally ill, the main work requires nurses to understand the dysfunctional internal processes. The nurses are responsible for performing the psychiatric assessment of their clients. The actual assessment consists of gathering the data and verifying the data. The use of a standardized tool facilitates the assessment process. The assessment covers social, physical, emotional, cultural, cognitive, and spiritual aspects of the individual. It elicits the information about the system in which the person operates. Specially trained psychiatric nurses take a nursing history and make assessments of client's pattern of difficulty and progress towards their resolution. There are many structured format as focus charting etc that nurses are not following. Thus an attempt is being made to develop an 'ideal documentation guidelines' for patients with mental health problems and to strengthen the documentation system. Good quality nursing documentation enables transparent and consistent approaches to the planning and delivery of care; it is the cornerstone for professional practice⁵.

Health records may be paper documents or electronic documents, such as electronic medical records, faxes, e-mails, audio or video tapes and images. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. Documentation is an accurate account of what occurred and when it occurred. Nurses may document information pertaining to individual clients or groups of clients. The reason for documentation includes promoting good nursing care, to meet professional and legal standards, medico – legal cases etc. A study to assess the Comparison of medical, surgical and oncology patients' descriptions of pain and nurses' documentation of pain assessments where Eighty-four nurse-patient dyads were studied to obtain descriptions of pain from medical, surgical and oncology patients experiencing pain. These descriptions were compared with the documentation of pain assessment recorded by the nurses providing care to these patients. Neither the descriptions of pain nor the amount of information documented about that pain differed significantly across the three groups. For each group, nurses documented significantly less than 50% of what the patients described. Inadequate documentation of pain assessment has legal and continuity of patient care implications⁶.

MATERIALS AND METHODS:

A comparative descriptive research design was adapted to assess the level of expectation of documentation by administrative nurses and actual performance by staff nurses. Target population was administrative nurses and staff nurses working in selected settings. A checklist to assess the expectation of documentation, a rating scale to know the accuracy of documentation after actual performances and a checklist to know the documentation behaviour of staff nurses during actual performance were used. Expert opinion and pilot study was conducted for the purpose of validity and reliability of the tool and was found to be feasible and valid. Reliability of tools assessed r=0.90, 0.93 and 0.80 respectively. Twenty five administrative nurses filled there expectation of documentation quality checklists, 25 staff nurses behaviour were assessed during actual performance and randomly assessed 100 of documents created by them about selected procedures eg admission, discharge, specific incidents(adverse incident like violence, side effects of drugs, emergency etc) and selected procedures (IV injections ,ECT care, mental status examination etc). Data was collected in the hospital and analysed using mean, median, percentage, SD, t test. Levels of significance was set as p<0.05.Ethical committees approval obtained and informed consent forms were signed by the staff nurses and administrative nurses before enrolment. Obtained authorities permission and confidentiality was maintained during assessment of hospital documents.

Documentation in terms of behaviour during actual performance was categorised in 4 levels: proper(Done completely, no omission, no mistakes), almost proper(done with 1 or 2 omissions or mistakes) , partially proper(not done or > 1 or 2 omissions or errors observed in psychiatric care area nurse Improper (not done or >3 omissions or errors). Among 30 behaviours 6 were observed while performing procedure and 24 observed during preparation of document. Check list for documents assessment consists of 4 negatively scored behaviours and 27 positively scored behaviours. Score was as follows proper behaviour (91-100), almost proper (81-90), partially proper (76-80), and improper behaviour (0-75 score) respectively.

Real hospital document level checked after randomly selected 100 documents with baseline information and a checklist. Baseline consists of 5 items document code, type of document, date and time of documentation, routine or incidental, document generated by (senior staff nurse/staff nurse/ANS). Rating scale developed to check accuracy of document consists of 30 items rated with SD = 1(not done or errors >3), D= 2(Not done or errors more than 2), A= 3(done with 1 or 2 errors or omissions) and SA=4 (Done without error or omissions) respectively. Total score was 120 and 30 statements present related psychiatric nurses expected behaviour during an ideal documentation of patient information which maintained the accuracy of document. If the document score below 90 is inaccurate, above 91-96 partial accurate, 97-108 almost accurate and 109-120 accurate.

RESULTS:

Table 1: Frequency and percentage distribution of administrative nurses N= 25

Sl. No.	Variables	Frequency (f)	Percentage (%)
1.	Age in years 21-30 31-40 41-50 >50	11 9 4 1	44 36 16 4
2.	Gender Male Female	6 19	24 76
3.	Qualification Diploma Under graduate Post graduate Doctoral	3 22	12 88
4.	Year of experience < 1 year 1-3 year 3-5 year >5 year	1 11 4 9	4 44 16 36

Table 2: Distribution of subjects according to the expectation of documentation in terms of staff nurses behaviours N=25

Expectation of documentation (behaviours)	Frequency (f)	Percentage (%)
Improper (not done or more than 5 errors or omissions)	1	4
Partial proper (not done or 1or2 errors or omissions)	2	8
Almost proper (Done with1or2 Errors or omissions) Proper (Done without 1 omissions Or Errors)	7 15	28 60

Table 2 indicates that, majority of administrative nurses 60% had proper expectation of documentation behaviours, 28% had expectation of almost proper documentation behaviours, 8% had expectation of partial proper documentation behaviours and 4% had expectation of improper documentation behaviours in the psychiatric care settings.

Table 3:Mean standard deviation and mean percentage of expectation of documentation N=25

Mean	Median	Standard deviation	Mean percentage (%)
27.72	28.00	2.37	92.4

Mean score obtained in expectation of documentation in terms of behaviours mean was 27.72 and mean percentage score 92.4% with a SD 2.37

Table 4: Frequency and percentage distribution of staff nurses N=25

Sl. No.	Variables	Frequency (f)	Percentage (%)
1.	Age in years 21-30 31-40 41-50 >50	25	100
2.	Gender Male Female	11 14	44 56
3.	Qualification Diploma Under graduate Post graduate	6 18 1	24 72 4
4.	Year of experience < 1 year 1-3 year 3-5 year >5 year	11 13 1	44 52 4

Table 5: Distribution of subjects according to the accuracy of documentation (During performance) rating scores, frequency, mean and SD of each area respectively admission procedure, discharge procedure, selected procedures and specific incidents. N=25

Accuracy of documentation	Done without Single Omission and Error (f) (4)	Done with At least 1or2 Omission Or errors (f) (3)	Not done Or >3 Omission Or errors (f) (2)	Not done Or>4 Omissions Or errors (f) (1)	total score	Mean and SD
Admission procedure (9 items)
All entries legible	4(1)	72(24)	0	0	3.04	3.27 0.006
All entries with sig and name	4(1)	72(24)	0	0	3.04
All entries with date	16(4)	63(21)	0	0	3.16
Nursing assessment thoroughly stated	20(5)	60(20)	0	0	3.2
Patient identity , IP no Visible page wise	36(9)	39(13)	6	0	3.24
Past present psychiatric history documented	28(7)	54(18)	0	0	3.28
All document intact Organized and together	32(8)	51(17)	0	0	3.32
Entries clearly timed	24(6)	54(18)	2(1)	0	3.2
Word routine explained to patient and documented	36(9)	63(21)	0	0	3.96
Discharge Procedure (4 items)
Discharge note completed	8(2)	69(23)	0	0	3.16	3.13 0.03
Health education documented	8(2)	69(23)	0	0	3.16
Stat medication and Indication explained and documented	12(3)	66 (22)	0	0	3.12
Discharge note documented	16(4)	57(19)	4(2)	0	3.08
Selected procedures (6 items)
Medication as per order	8(2)	69(23)	0	0	3.08	3.18 0.004
IM injection steps recorded	16(4)	63(21)	0	0	3.08
IV injection Process documented	12(3)	66(22)	0	0	3.12
Height and weight recorded	24(6)	57(19)	0	0	3.24
MSE report documented	16(4)	63(21)	0	0	3.16
Wound care documented	64(16)	21(7)	4(2)	0	3.16
Specific incidents recording (11items)
Errors indicated appropriately	72(18)	18(6)	2(1)	0	3.68	3.17 0.2
Change in patients Condition recorded	24(6)	57(19)	0	0	3.24
Lab report charts Documented	12(3)	66(22)	0	0	3.12
Care plan documented	24(6)	57(17)	0	0	3.24
Patient, family, physician communication documented	36(9)	45(15)	2(1)	0	3.32
Self mutilated Behaviour documented	12(3)	63(21)	2(1)	0	3.08
Misbehaviour in Therapy sessions recorded	28(7)	36(18)	0	0	2.58
Type, duration and Status of restrains	36(9)	48(16)	0	0	3.36
Daily progress	28(7)	45(15)	6(3)	0	3.16
Incident of aggression and Violence recorded	8(2)	69(23)	0	0	3.08
ADL related issues documented	4(1)	72(24)	0	0	3.04

Indicates that, majority of staff nurses documented with 1or 2 errors or omissions in four areas .Area wise means (SD) were discharge procedure 3.13(0.03), specific incident recording 3.17(0.2), discharge procedure 3.18(0.004) and admission procedure 3.27 (0.006) respectively. Highest score observed 3.96 is in admission procedure document (9th item) and lowest score 2.58 in specific incident recordings document (7^th Item).

Table 6: Distribution of subjects according to the actual behaviours of nurses during actual documentation N=25

Expected performance behaviours	Frequency (f)	Percentage (%)
Improper(not done or 3or4 errors or omissions) Score 1	0	0
Partial proper (not done or 1or2 errors or omissions) Score 2	0	0
Almost proper (Done with1or2Errors or omissions) Score 3	14	56
Proper (Done without 1 omissions Or Errors) Score 4	11	44

Indicates that, majority of staff nurses 56% had almost proper actual behaviours of documentation and 44% had proper behaviours of documentations.

Table 7: Mean standard deviation, mean and percentage of actual behaviours of nurses (during documentation) N=25

Mean	Median	Standard deviation SD	Mean percentage (%)
26.32	26	1.06	87.73

Mean score obtained in actual documentation was 26.32 and mean percentage score 87.73% with a SD 1.06.

Table 8: Comparison between actual documentation expectation of documentation using independent t test N=25+25

Group	Mean	Mean %	SD	t value	p value
Actual documentation	26.32	87.73	1.06	2.690	.011*
Expectation documentation	27.72	92.43	2.37

*Significant

The data in table 8 shows that mean difference of expectation of documentation (87.73%) was higher than the mean difference of actual performance (92.43%). In computed t test calculated p value is less than 0.05, which means there is significant difference between actual documentation and expectation of documentation. Hence research hypothesis is accepted and null hypothesis is rejected.

DISCUSSION

In this present study among 25 subjects the expectation of documentation by administrative nurses shows that 60% administrative nurses had proper expectation of documentation only 4% administrative nurses had improper expectation of documentation. The mean (27.72) and mean percentage (92.4%) of expectation of documentation by administrative nurses shows that they have a higher expectation regarding documentation.

The main area covered includes the admission, discharge, selected procedure, and specific incident. Among the above mentioned areas the mean percentage of specific procedure (98.6%) shows the highest expectation by administrative nurses. Admission (90.2%), discharge (93.6%), specific incident (85.6%).

The findings of another study show the accuracy of nursing documentation in patient records in hospitals. This study included the areas such as (1) record structure, (2) admission data, (3) nursing diagnosis, (4) nursing interventions, (5) progress and outcome evaluations and (6) legibility of nursing reports. 95% of the records revealed a scale score not higher than 5. The study findings are incongruent with present study; it shows the domain ‘admission’ had the highest scores: 80% of the records revealed a scale score over 5⁷.

CONCLUSION:

Nursing documentation provides an account of the judgement and critical thinking used in the nursing process (i.e. assessment, diagnosis, planning, intervention and evaluation). Accurate, timely documentation reflects care provided; meets professional, legislative and agency standards; promotes enhanced nursing care; and facilitates communication between nurses and other health care providers.

The present study was done to assess “the expectation on documentation and actual performance among nurses working in selected areas of a hospital in Mangalore, with a view to prepare ideal documentation guidelines.” An ideal documentation guidelines was developed and distributed among staff nurses after data analysis to improve their documentation.

REFERENCE:

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Received on 15.01.2016 Modified on 17.02.2016

Accepted on 24.02.2016 © A&V Publications all right reserved

Asian J. Nur. Edu. and Research. 2016; 6(2): 260-264.

DOI: 10.5958/2349-2996.2016.00050.1