Nursing Documentation in Long-Term Care Settings

Philippe Voyer, Jane McCusker, Martin G. Cole, Johanne Monette, Nathalie Champoux, Antonio Ciampi, Eric Belzile, Minh Vu and Sylvie Richard

Clinical Nursing Research, 2014, vol. 23, issue 4, 442-461

Abstract: In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above ( N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.

Keywords: nursing documentation; long-term care setting; delirium (search for similar items in EconPapers)
Date: 2014
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Persistent link: https://EconPapers.repec.org/RePEc:sae:clnure:v:23:y:2014:i:4:p:442-461

DOI: 10.1177/1054773813475809

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