Advancing nursing documentation—An intervention study using patients with leg ulcer as an example

Abstract 

Aim

The aim was to implement and evaluate a standardised nursing record, using patients with leg ulcer as an example, regarding the content of the nursing record and district nurses’ experiences of documentation.

Method

This was a prospective, stratified and randomised intervention study, with one intervention group and one control group. A standardised nursing wound care record was designed and implemented in the electronic patient record in the intervention group for a period of 3 months. Pre- and post-intervention audits of nursing records [n=102 and n=92, respectively] were carried out and 126 district nurses answered questionnaires pre-intervention and 83 post-intervention.

Result

The standardised nursing wound care record led to more informative, comprehensive and knowledge-intensive documentation according to the audit and district nurses’ opinions. Furthermore, the district nurses’ self-reported knowledge of nursing documentation increased in the intervention group. When the standardised nursing wound care record was not used, the documentation was mostly incomplete with a lack of nursing relevance. There were no differences in the district nurses’ experiences of documentation in general between the two groups.

Conclusion

Using the standardised nursing wound care record improved nursing documentation meeting legal demands, which should increase the safety of patient. There was however a discrepancy between the nurses stated knowledge and how they carried out the documentation. Regular in-service training together with use of evidence based standardised nursing records, as a link to clinical reasoning about nursing care, could be ways effecting change.

Keywords: Nursing records, Community health nursing, Primary health care, Medical records computerized, Wound care