Patient care information is often being recorded by nurses in an “inaccurate, inconsistent, repetitive and incomplete” way, leading to potential safety concerns, according to researchers.
A study at a large acute trust in England, which was led by researchers in Nottingham, found nurses sometimes completed documentation retrospectively without full knowledge that care had actually been completed.
One nurse in the study described a case in which a patient collapsed, but when their notes were consulted there was no information about why they had been admitted.
In other instances, documentation had been filled in before nurses had carried out procedures to ensure they did not forget ahead of any potential audits.
The researchers – Liz Charalambous, a staff nurse at Nottingham University Hospitals NHS Trust, and Sarah Goldberg, a professor in older persons’ care at Nottingham University – also heard nurses that could not always find the information they needed, despite it being recorded in several places.
Missing information, errors and duplications were partly being caused by nurses feeling exasperated by the sheer amount of paperwork they had to complete, and the fact they believed it was often repetitive and took them away from patient care, according to the study authors.
The study – titled ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care? and published in the Journal of Research in Nursing – looked at nurse documentation for older patients on acute wards in England. It involved in-depth interviews at the start of 2015, with eight nurses employed by Nottingham University Hospitals NHS Trust.
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