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RESEARCH PAPER
A meta-study of the essentials of quality
nursing documentationijn_1815 112..124
Diana Jefferies RN BA (Hons) PhD (USyd)
Project Officer, Centre for Applied Nursing Research, Liverpool BC, New South Wales, Australia
Maree Johnson RN BAppSci (Cumb) MAppSci (Cumb) PhD (ANU)
Research Professor, School of Nursing and Midwifery, Acting Director, Centre for Applied Nursing Research (Joint facility of SSWAHS and the
University of Western Sydney), College of Health and Science, University of Western Sydney, Penrith South, DC, New South Wales, Australia
Rhonda Griffiths AM DrPH MSc (Hons) Bed (Nursing) RM RN
Head of School, School of Nursing and Midwifery, College of Health and Science, University of Western Sydney, Penrith South, DC, New South
Wales, Australia
Accepted for publication October 2009
Jefferies D, Johnson M, Griffiths R. International Journal of Nursing Practice 2010; 16: 112–124
A meta-study of the essentials of quality nursing documentation
The aim of this study was to synthesize all relevant information about nursing documentation and present the essential
aspects of quality nursing documentation. Literature searches, limited to the English language, were conducted on both
CINAHL (1982 to week 3, April 2008) and MEDLINE (1996 to April 2008) using the following search terms: attitude,
audit, care, culture, documentation, guideline health, in service, legal, liability, medical, nurses, nursing, organizational,
patient, personnel, planning practice, quality, records, research and training. One hundred and seventy-one papers were
reviewed for their relevance to the clinical question. Twenty-eight articles were read by two researchers. Data informing
the clinical question were extracted and categorized into key concepts by an analysis of similarities. The seven major
themes (essentials) of quality nursing documentation were identified. This paper has reviewed contemporary literature,
research evidence and local policies to identify the seven essential components of quality nursing documentation. Some of
the barriers or more controversial aspects of the final policy are described.
Key words: content, documentation, meta-synthesis, nursing, quality.
INTRODUCTION
Quality nursing documentation has the potential to
improve patient outcomes through the recording of the
patient’s condition and the patient’s responses to nursing
interventions. Through appropriate written presenta-
tions, all members of the health-care team can be
informed of a patient’s status and care.1However, its
value as an important source of reference in the health-
care system is undermined because there is much con-
fusion about the exact nature of quality nursing
documentation. With the impending introduction of elec-
tronic health records, nurses are alerted to the need to
improve their documentation of the care they deliver to
their patients on a daily basis.
The Department of Health in NSW defines the Health
Care Record as ‘a documented account of a person’s
health, illness or treatment in a hard copy or electronic
Correspondence: Diana Jefferies, Centre for Applied Nursing Research,
Locked Bag 7103, Liverpool BC, NSW 1871, Australia. Email:
diana.jefferies@sswahs.nsw.gov.au
International Journal of Nursing Practice 2010; 16: 112–124
doi:10.1111/j.1440-172X.2009.01815.x© 2010 Blackwell Publishing Asia Pty Ltd
form’.2The purpose of nursing documentation in NSW is
to: provide effective communication to the health-care
team, provide for a person’s effective continuing care,
enable evaluation of a person’s progress and health
outcome and retain its integrity over time. Clinical note-
taking and record-keeping play an important role to all
health-care professionals, including nursing, and this was
recently emphasized in a public inquiry into health ser-
vices. Commissioner Garling stated—‘clear, reliable, and
accurate communication between health professionals is
essential to patient safety and the efficient operation of
NSW public hospitals’.3
Garling’s conclusions confirmed a retrospective audit
of root cause analyses of incidents recorded on the Inci-
dent Information Management Systems at one Sydney
metropolitan tertiary referral hospital. Nearly half of the
adverse events that occurred between April 2003 and
September 2004 were attributed to two factors: poor
communication and a lack of policy and procedure to
ensure that appropriate communication systems were
maintained. The audit also revealed that there was no
policy for nursing documentation covering the entire
health service.4A detailed review showed that nurses
had recorded all incidents of care given to the patient
such as hygiene, family visits and mobility, but the
patient’s physiological state and their response to
care could not be ascertained. In NSW, the development
of systems to assist nurses in producing quality
nursing documentation became a priority.5,6 The
purpose of this paper is to describe a systematic
approach to the review of existing literature on nursing
documentation. We have described elsewhere the
process of engaging clinicians and stakeholders in the
process of policy development, implementation and
evaluation. (Jefferies D. et al., unpubl. data, 2010).
The merits of written communication
Traditionally, nurses communicate information about
their patients orally. Therefore, modes of written com-
munication in nursing are not given the attention they
deserve.7,8 This has an unfortunate effect on nursing, with
this oral culture obscuring or concealing the ‘work’ of
nurses.9When nurses rely on oral, rather than written,
communication, they are limiting communication to their
own particular context by ignoring other sources of infor-
mation and the actual documentation provided by nurses
in relation to their patients. As communication becomes
reliant on what one person says to another, current cir-
cumstances dictate meaning. Knowledge judged as irrel-
evant is forgotten.10
Written communication provides a much wider plat-
form for the storage of knowledge because the work of
memory and conservation is inherent in the written
word.11 It provides nursing with a much greater reposi-
tory of knowledge and enables the nurse to consider a far
greater number of options when making a decision about
the patient’s condition or their care.
Yet, nurses are not using their nursing documentation
effectively. Although somewhat dated at this time, Allen
argued that nurses could not consult their nursing docu-
mentation to inform their actual practice because of the
realities of their work in the clinical setting. Nursing
documentation has become little more than an ‘account-
ing mechanism’ used to defend the actions of those
working in hospitals in a legal context rather than a record
of the patient’s condition and care.12
Nursing documentation defines the
performance of nursing practice
Nursing documentation is important because it defines
the nature of nursing itself by documenting the outcome
of patient care. Not only is nursing documentation a
repository of knowledge about the patient, it is also veri-
fiable evidence showing how decisions are made and
records the results of those decisions.13 As a powerful
communication tool, it provides evidence of the work of
the nurse and evaluates its success as a written record of
the patient’s journey. Nursing documentation is a tool
that demonstrates what the nurse actually does for the
patient.14
In order to record the patient’s experience of their
condition and care, nursing documentation must describe
the care given to the patient by the nurse as accurately as
possible. A study conducted by Brooks in 1998 showed
that nurses were competent in documenting scientific,
technical and organizational strategies of care. However,
often nurses did not record their own sophisticated under-
standing of the patient’s experience demonstrated by the
recording of incidences of teaching by the nurse or the
psychosocial care. This care lies at the very essence of
nursing practice.15 Frank-Stromberg and Christensen took
Brook’s work a step further and identified five reasons
why nurses did not document these aspects of nursing
care:16
Essentials of nursing documentation 113
© 2010 Blackwell Publishing Asia Pty Ltd
1. Nurses were not motivated to write about psychoso-
cial concerns because they had difficulty accessing appro-
priate language to accurately describe these incidences of
care.
2. As nursing language has not evolved to incorporate
these aspects of care, the descriptions of these incidences
tended to be imprecise leading to inconsistent reporting in
the nursing documentation.
3. Nursing documentation tended to focus on the routine
aspects of care without demonstrating any clinical judge-
ments or decisions.
4. Rather than recording all aspects of their care, nurses
assumed that their readers would know that care suitable
to the procedure or treatment was performed.
5. Often verbal accounts of care were far richer than
nursing documentation because nurses did not have
adequate writing skills to describe their nursing practice.
Aim of the study
The aim of this study was to synthesize all relevant infor-
mation about nursing documentation. The researchers,
working with 15 registered nurses from one metropolitan
Area Health Service, hereafter referred to as the review
team, sought to develop systematically the essential
aspects of nursing documentation that would guide nurses
to produce quality nursing documentation across dispar-
ate clinical settings.
METHODS
Research design
A wide range of material requiring synthesis was found by
an initial examination of the research literature.17 Our
goal was to define the nature of nursing documentation by
developing the most appropriate review approach to syn-
thesize and present the material. The high degree of diver-
sity within the research literature led researchers to use a
model based on a meta-study approach. The literature was
read and re-read by at least two researchers to identify
major themes, which were coded and rated in order of
importance in response to a formulated clinical question18
Although researchers emphasized the significance of
methodological rigour, other factors, such as the value of
the research in real-world terms, were considered also.17
Therefore, the importance of the research articles was not
only their analytic and interpretive methods but also
their content or the new insights presented in their
findings.19
Search methods
Clarifying the issues associated with nursing
documentation
An initial search of CINAHL and MEDLINE from 1998 to
2008 sought to clarify what the research literature iden-
tified as the most important issues in nursing documenta-
tion. Five articles were selected to initiate thinking about
what issues were important or essential to documenta-
tion. The themes identified in this initial literature search
were:
1. The purpose of nursing documentation.7
2. Whether patient care should be documented by
including all aspects of care or by excluding those aspects
of care that are already charted in the nursing care plan.16
3. How to document the actual work of the nurses.15
4. How to ensure that the central concern of the nursing
documentation is the care and the concerns of the
patient.20
Literature search based upon a formulated
clinical question
A second search of the literature was conducted to iden-
tify all the major research about nursing documentation
that could be found to answer the following clinical ques-
tion devised by the review team:
What are the main aspects (principles) of quality
(accurate, concise, relevant). nursing documentation
of patient care?
The search strategy sought to find published papers on
CINAHL 1982 to week 3, April 2008, and MEDLINE
1996 to April 2008 and limited to the English language.
The search was undertaken using the following terms:
attitude, audit, care, culture, documentation, guideline,
health, in service, legal, liability, medical, nurses, nursing,
organizational, patient, personnel, planning, practice,
quality, records, research and training. Once these articles
were found their relevance needed to be established.
All studies identified during the search were assessed as
meeting the criteria of being within or beyond the scope
of the clinical question based on the information provided
in the title and abstract. A full paper of all articles found to
be within the scope of the question was retrieved and the
entire article was assessed to determine the reoccurring
themes found in the literature. Once the full paper was
read, articles deemed to be outside the scope of the ques-
tion were excluded also from the study but their details
114 D Jefferies et al.
© 2010 Blackwell Publishing Asia Pty Ltd
and reasons for exclusion were recorded (Table 1). The
major reason for exclusion was that the article’s major
focus was not directly related to establishing quality in
nursing documentation.
One hundred and seventy-one articles were identified
in the original search. When the review team examined
the full papers, 28 articles, mostly retrospective studies of
audits, were selected to be included in the study. The
review team were divided into groups and each was given
a number of articles to read so that key findings could be
identified and synthesized into a one- to two-page
summary. These key findings were collated into a
summary table (see Table 2).
The next step in this process of gathering all the rel-
evant research evidence available was to analyse policies
found in the 11 individual health facilities within the Area
Health Service on nursing documentation. Each of these
policies was analysed using a tool adapted from Kulig
et al.57 This information was collected so that it would be
possible to assess the concordance between the essentials
defined by this review with the existing policy require-
ments for nursing documentation.
Quality appraisal
The diversity of research designs in the papers made
assessing quality a difficult process as various papers
required different tools. Researchers assessed the quality
of all research materials by examining each article for the
following criteria: a sufficient explanation of the back-
ground, a clear statement of the research question or
objective, a full description of the method used, and a
clear presentation of the findings and, if appropriate, their
relevance to policy.58 If an article was identified as being
an expert opinion piece, quality was determined by the
System for the Unified Management, Assessment and
Review of Information tool development by the Joanna
Briggs Institute. The most important aspect of the quality
appraisal was to determine whether the article was able to
inform the formulated research question and add further
insight into the essentials of quality nursing documenta-
tion.58,59 No article was rejected on the grounds of quality
appraisal scoring alone.
Synthesis
Key findings were listed in point form in a summary table,
and then categorized further into key concepts by an
analysis of their similarities.18 Once this had been com-
pleted, the review team developed seven major themes
(essentials) of quality nursing documentation. The team
agreed by consensus that these seven major themes would
form the essentials of quality nursing documentation. The
method of collecting and synthesizing data from the
Table 1 Articles excluded from the study
Article Reason for exclusion
Allen, 199812 Focuses on the views of nurses
Ansell et al., 200721 Focuses on medical care received
Axelsson et al., 200622 Article is not about nursing documentation
Bjorvell et al., 200323 Does not answer initial question
Ehrenberg et al., 200124 Focus on the audit process
Friberg et al., 200625 Focuses on patient knowledge
Johann et al., 200726 Outside the scope of the initial question
Junttila et al., 200527 Outside the scope of the initial question
McCormick, 200528 Focus on testing and developing a computer system
Monsen et al., 200629 Focus on computerized documentation
Newman and Howse, 200730 Focus on attitudes to educational tutorial
Darmer et al., 200631 Discusses a model preordained and the adherence to this model
Thoroddsen and Ehnfors, 200732 Focus on change not quality
Lee, 200633 Focus on care plan design
Tornkvist et al., 200334 Focus on pain management
Ziegert et al., 200735 Focus on the next of kin
Essentials of nursing documentation 115
© 2010 Blackwell Publishing Asia Pty Ltd
Table 2 Summary of major themes
Article Type of study Extraction of major themes Quality rating Relationship to themes
Baath et al., 20079Retrospective audit review What is recorded might be inaccurate +Draws attention to difference between
oral and written communicationThere might be other routes of information such as verbal handover, but this needs
to be reflected in the clinical record
Records are used as quality indicators
Bergh et al., 200736 Chart audit using pedagogical
key words to assess if
pedagogical activities are
recorded frequently
Discussed the importance of pedagogical activities in nursing documentation +2, 4
Bjorvell et al.,
200237
Pretest/post-test Nursing diagnosis and goal setting is seen as less meaningful than the patients’ status ++ 7
Nurses document observations but rarely conclusions
Nursing diagnosis and goals in practice are still concepts unfamiliar to nurses in
Sweden where practice generally follows a medical paradigm with patient
problems seen as medical not nursing
Bjorvell et al.,
200338
Quasi-experimental
longitudinal study
Quality vs. quantity of nursing documentation +1, 6
Do nurses only document for legal reasons
Nurses good at documenting patient observations/physiological results but not
nursing interventions, judgements, or decisions made by nurses regarding patient
care and outcomes
Need for in-depth training of nurses re: documentation
Cheevakasemsook
et al., 20068
Multiple methods: in-depth
interviewing, participant
observation and nominal
group processing
No guidelines for a holistic approach to documenting +2, 6
The nursing documentation system especially the descriptive style is inappropriate
for the workload or responsibilities of clinical nurses
Inaccessibility wastes a lot of time
Considine et al.,
20065
Pretest/post-test Written ED standards improve documentation of initial assessment of ED
documentation
+Confirms the need to provide nurses with
direction to help them produce quality
nursing documentation
Davis et al., 200039 Chart audit The Health-Related Quality of Life conceptual model provided the structure to
evaluate the documentation system and provided a transition to a computer-based
client record
+The themes are applicable to the
electronic medical record
Ehrenberg and
Birgersson,
200340
Literature review There needs to be more research into the knowledge base for assessment, diagnosis,
interventions and outcomes of patient care in records
+Confirms the need to provide nurses with
direction to help them produce quality
nursing documentation
116 D Jefferies et al.
© 2010 Blackwell Publishing Asia Pty Ltd
Ehrenberg et al.,
200441
Chart audit Need for organizational support for implementation of guidelines and ongoing
education
+4
Does the legality of documentation compel nurses to record information about a
patient rather than record nursing interventions
Nurses record physiological observations well but not holistic care, e.g. sleep and
activity patterns
Ehrenberg et al.,
200124
Retrospective descriptive
design
Discusses what needs to be documented. Clinical Guidelines to accompany a
structured documentation approach
+4
Documentation might vary amongst differing health populations
Nurses need to document their outcomes
Gebru et al.,
200742
Descriptive study from
archival data
Notes should reflect more culturally congruent care data +1
There is a need to promote culturally competent nursing care
Culturally competent nursing care can only occur when the patients’ values and
perceptions of care are known by the nurse and physician
Grafton et al.,
200643
Retrospective chart audit Factors contributing to successful implementation included buy-in levels of the
organization, identification of practice champions, access to educational activities
and community experts, the establishment of policy expectations, the inclusion
of abuse inquiry reminders on documentation forms and positive feedback from
programme managers
+Demonstrates the importance of
education and audit to ensure that
quality nursing documentation is
produced
Gunningberg and
Ehrenberg,
200444
Cross-sectional survey of
retrospective chart audits
What is recorded might be inaccurate +2
There might be other routes of information such as verbal handover, but this needs
to be reflected in the clinical record
Higgens
et al.,200245
Action research Nursing staff identified the source of the problem as being the unsuitability of the
chart being used and were determined to design their own
+Establishes the need to document all
aspects of patient care
Improvement in the charting of bowel and treatment of constipation took some
time after the chart was implemented
Hyde et al., 200514 Discourse analysis Nursing practice is difficult to define if our role and function is not clearly
documented in the patient’s clinical record
+2
Nurses are excellent verbal communicator but not good at documenting
Idvall and
Ehrenberg,
20026
Chart audit Nurses overestimate the quality of their own documentation +Demonstrates the importance of
education and audit to ensure that
quality nursing documentation is
produced
Karkkainen and
Eriksson, 200346
Chart audit Documentation is an essential part of developing nursing care as they are a written
aid and legal document, which logically describes patients’ nursing care
+7
Essentials of nursing documentation 117
© 2010 Blackwell Publishing Asia Pty Ltd
Table 2 Continued
Article Type of study Extraction of major themes Quality rating Relationship to themes
Karkkainen and
Eriksson, 200513
Qualitative study Patients physical state was well documented but emotional state and support were
neglected before intervention
+2
Korst et al., 200347 Time-in-motion study Implementation of electronic medical records was not associated with excessive time
spent on documentation
+
Langowski, 200548 Secondary source article Discusses benefits of computer-based documentation not documentation content +Demonstrates that themes are relevant to
electronic medical record
Larrabee et al.,
200149
Quasi-experimental study Study focused on documentation completeness in a computerized nursing
information system
+Demonstrates that themes are relevant to
electronic medical record
Murray et al.,
200150
Exploratory survey When is an entry timely and valid, and when does it become so late it looses
credibility?
+5
Newman and
Howse, 200730
Post-test mixed design/
quantitative and qualitative
Focus on the PDA tool to help nursing students to develop clinical judgement and
documentation skills
+Demonstrates that themes are relevant to
electronic medical record
Satzinger et al.,
200551
Telephone survey Transfer of information between hospitals and home care services upon hospital
admission or discharge of patients in need of long-term nursing care was
inadequate; accompanying form was developed to close the gap
-5
Shayah et al.,
200752
Chart audit Documentation based on the experience of surgeons is an aide-memoir, a summary
of a discussion, agreement or action—a summary of what has happened; these
findings should be given to patients
+5
Smith et al., 200553 Chart audit, observation, pre
test/post test of computer
project implementation
Explores nurse attitudes towards computerization +Demonstrates that themes are relevant to
electronic medical record
Staunton and
Chiarella,
200854
Opinion Clarifies legal position of health-care records. Describes principles of good and bad
practice
N/A 3, 5, 7
Tornvall et al.,
200755
Questionnaire/chart audit An essential source of knowledge about patient care +7
The methodological quality is reported by the following system: ++ when all or most of the criteria have been fulfilled; +when some of the criteria have been fulfilled; and—when few or none of the criteria
has been fulfilled.56
118 D Jefferies et al.
© 2010 Blackwell Publishing Asia Pty Ltd
literature and existing policies evolved throughout the
process.59 Researchers could continue to cast the net as
widely as possible in order to gather as much information
as possible to answer the research question.
The essentials of quality nursing documentation iden-
tified from the research are found in Table 3 and are
discussed later in the findings.
RESULTS
Each theme is discussed in terms of how the research
papers included in the study apply to it.
Theme 1: Nursing documentation should
be patient centred
The patient’s own perception of their condition and
their response to care should be the basis of the content
of nursing documentation.20 This requires the nurse to
record anything that the patient might say to describe
their condition or any observations that the nurse makes
about the patient’s condition.42 An example of how
these observations might be recorded is found in the fol-
lowing:
Mr...complained that he had a headache all day and it
was making his vision blurry. He asked that the blinds be
closed in his room. It was observed that Mr...wasshielding
his eyes from the light with his hands.
This example brings together information from the
patient and the nurse to describe the clinical
context. Once this observation has been made, the
nurse should also document any intervention such as
reporting the symptoms to the medical officer or giving
the patient analgesia. The nurse would also ensure
that the patient’s response to this intervention be
documented.38
Theme 2: Nursing documentation must
contain the actual work of nurses
including education and
psychosocial support
Nurses must document their interventions in a manner that
demonstrates their care of the patient.13 The oral, rather
than written, culture of nursing encourages nurses to dis-
cuss their interactions and interventions with patients in
a complex and sophisticated manner with other nursing
colleagues. However, this information is rarely re-
corded in the nursing documentation.14,15,44 Nurses must
be mindful that they record all instances of psychosocial
support or patient education to demonstrate how their
work as a nurse has assisted the patient.8,25,36 Nursing
documentation should be structured to demonstrate
the benefit of these interventions, showing why such
interventions were necessary, what was done and the
outcome for the patient/client.
Theme 3: Nursing documentation is
written to reflect the objective clinical
judgement of the nurse
The nurse must document what they see or what the
patient says to them, not the assumptions the nurse makes
about the patient’s condition or care.60 The nurse should
avoid using words such as ‘appears’ or ‘seems’ and should
write all observations in a descriptive manner.54 For
example:
Don’t write: the patient appears to be asleep
Write: when observed the patient was asleep
Or
Don’t write: the patient seems to be drunk
Write: the patient was walking in an unsteady manner,
his speech was slurred and his breath smelt of alcohol
Table 3 Essentials of quality nursing documentation
Theme 1 Nursing documentation should be patient centred
Theme 2 Nursing documentation must contain the actual work of nurses including education and psychosocial support
Theme 3 Nursing documentation is written to reflect the objective clinical judgement of the nurse
Theme 4 Nursing documentation must be presented in a logical and sequential manner
Theme 5 Nursing documentation should be written contemporaneously, or as events occur
Theme 6 Nursing documentation should record variances in care within and beyond the health-care record
Theme 7 Nursing documentation should fulfil legal requirements
Essentials of nursing documentation 119
© 2010 Blackwell Publishing Asia Pty Ltd
In each case, the first example represents an assumption
the nurse has made about the patient, whereas the second
example simply records what the nurse has observed.
Theme 4: Nursing documentation
must be presented in a logical and
sequential manner
This asks the nurse to demonstrate two particular aspects
of their care. First, the nurse is asked to show how deci-
sions for planned care were made and, second, to confirm
that the patient has received all the care they require.36
The nurse must record all problems experienced by the
patient, how mutually agreed inventions are implemented
and their outcome in the nursing documentation. If the
patient continues to experience problems, the nurse
should demonstrate in their documentation that the
problem has been re-evaluated and further solutions were
sought.41 This particular cycle of the identification, inter-
vention, outcome and re-evaluation should continue until
all problems are resolved.24
Theme 5: Nursing documentation should
be written as events occur
To ensure that all nursing documentation is an accurate
reflection of the patient’s condition and care, the nurse
should record events as they occur. If a nurse waits until
the end of a shift to document the day’s events, it can be
difficult to recreate an accurate sequence of events. Docu-
menting events as they occur guarantees that important
information about the patient’s condition and care is not
forgotten if subsequent events take place.52,54
Theme 6: Nursing documentation should
record variances in care
Nursing documentation should be clear and concise so
that it is an effective communication tool. One method of
ensuring this clarity is to document information that is not
found in other entries of the health-care record and which
indicates that the patient’s condition and their care has not
changed.16 One example of unnecessary duplication is
observations already recorded on the observation chart
and which show that the patient’s condition remains
within normal limits. Other superfluous information can
include a denial of pain if the patient’s condition or care
has not changed. However, if the denial of pain represents
a change in the patient’s condition, it should be recorded
in the nursing documentation.
It is often argued that if a task performed by the nurse
is not entered into the nursing documentation, it is
assumed in a legal context that this task has not been
performed and that the patient has suffered neglect from a
lack of care.61 But, it is this desire to list all tasks carried
out by the nurse for the patient that denies the patient’s
point of view in nursing documentation.8From a legal
standpoint, when the nurse simply creates a list of tasks, a
broader and demonstrated understanding of the patient’s
condition and care has not been achieved.38
It should be acknowledged that this theme has proven
to be controversial, and all clinical areas must use their
own professional judgement and identify individual
issues that must always be included in the nursing
documentation.
Theme 7: Nursing documentation should
fulfil legal requirements
Further to the discussion of how nurses should present
their documentation to ensure that they meet legal
requirements, they are advised to document the patient’s
condition and care in a manner that explains why decisions
about that care were made.55 Therefore, again, it must be
reiterated that nursing documentation must be more than
a list of tasks performed by the nurse. It must be suffi-
ciently comprehensive to present a continuous narrative
of the patient’s experience that demonstrates how the
nurse has understood the patient’s condition and how they
have dealt with any problems that might be evident.37,46 If
nursing documentation gives an accurate, objective and
sufficiently comprehensive record of a patient’s condition
and care, it will support the oral explanations a nurse
might be required to give in a legal context.
Nurses must also ensure that the presentation of
nursing documentation complies with legal requirements
(see Table 4).
DISCUSSION
The search of literature about nursing documentation
revealed a diversity of opinion on the subject. The
purpose of the meta-study was to identify the reoccurring
themes in order to develop a consistent approach that all
nurses could follow when documenting their patient’s
condition and the care they had given to the patient.17,19,56
This diversity focused the efforts of the researchers on the
content, rather than on the form, of the literature. The
data required to develop the major themes had to be
extracted through an iterative process involving at least
120 D Jefferies et al.
© 2010 Blackwell Publishing Asia Pty Ltd
two researchers engaged in the reading and re-reading of
the literature to discover what aspects of nursing docu-
mentation were consistent throughout the literature.17
This process was complicated further by an analysis of the
existing policy documents at both a state and health facil-
ity level. The major concern of these policies was the legal
aspects of nursing documentation, but they offered little
direction to nurses about the content of their documen-
tation. Although we recognized the importance of ensur-
ing that the legal requirements were clearly stated, the
emphasis of the research was on investigating the content
of nursing documentation.
The examination of papers and data extraction was
based on the methodology of the qualitative meta-
synthesis. By focusing on findings, rather than on method,
the meta-study approach gave the researchers the freedom
to investigate a wide diversity of papers, which might
otherwise be excluded from the process during the quality
rating phrase.18,59 As Sandelowski et al. comment impor-
tant findings might be discounted by what amounts to
nothing more than a surface mistake.17 Quality rating
proved to be a difficult component of the method as suit-
able and validated tools for the wide variety of papers
were not available.56 Although two researchers completed
a quality rating on each article and the results between the
two researchers were remarkably similar, its value must
be questioned because the literature could not be neatly
categorized into a specific research design.58
Another difficulty that arose during the period of the
study was that the consulting clinicians who commented
on the various drafts of the policy had their own specific
techniques of documenting their care. Researchers had to
develop an approach to nursing documentation that would
encompass all methods of documentation from the
systems approach to an approach based on problem-
solving techniques. This was a significant issue because the
final policy was intended to provide direction to all nurses
working in every clinical setting in the Area Health
Service. Thus, the goal of the review was to deliver a set
of essentials and to leave the actual format of the nursing
documentation to be decided by nurses in each clinical
setting.
Once the set of essential elements or the major themes
of nursing documentation were identified, their impor-
tance to the policy was determined by consensus.
Although the process of distilling the literature through
the localized experience of the clinicians produced a set of
major themes that were relevant, the final policy con-
tained elements that would require controversial shifts in
thinking and changes in clinical practice if the policy was
to be implemented successfully.
Controversial issues for clinical practice
The policy challenged nurses to document their care from the
patient’s point of view.
The findings of the literature search and synthesis dem-
onstrate that producing quality nursing documentation is a
complex exercise. Initial consultation with the directors
of Nursing and Midwifery Services in the Area Health
Service revealed that nursing documentation often repre-
sented nothing more than a list of tasks performed by the
nurse during his or her shift. It was difficult to identify the
patient’s condition and/or response to the care received.
Quality nursing documentation demands that the nurse
positions the patient at the centre of this documentation.
Therefore, a shift in the nurse’s perception of nursing
Table 4 An example of what legal requirements might be neces-
sary for nursing documentation
Nursing and midwifery documentation must be written legibly.
The patient must be identified by name, health-care record
number and date of birth at the top of each page of nursing
documentation either by an identifier, such as a sticker, or as
written by the nurse.
All entries must include the date and time using the
twenty-four hour clock when documentation occurred and
should include the signature, name and designation of the
nurse or midwife.
If using medical terminology, the nurse or midwife must be
sure of its exact meaning.
Incorrect entries must not be totally obliterated. A line should
be drawn through the entry before the writer continues. The
nurse or midwife should indicate that they have drawn the
line through the entry by placing their initial next to the
entry.
No entry concerning a patient’s care should be made on behalf
of another nurse or midwife.
Before using any form of abbreviation, nurses and midwives
must ensure that the abbreviation is approved in the
individual clinical setting. If there is any doubt, nurses and
midwives must not use any abbreviations and write all words
in full.
No blank lines are to be left between entries in the health-care
record.
Essentials of nursing documentation 121
© 2010 Blackwell Publishing Asia Pty Ltd
documentation from a platform to protect the nurse in a
legal situation to the patient is necessary.20 We have
encouraged our clinicians to consider using the patient’s
name in the written communication to assist them in
focusing their attention on the patient’s perspective and to
promote a holistic view of the patient.
Nurses were asked not to document routine information that was
recorded elsewhere in the healthcare record.
Clear and concise nursing documentation assists all
health-care professionals to detect changes in the patient’s
condition and assess the quality of the care. If nursing
documentation is crowded with information that could be
efficiently stored elsewhere, such as routine observations
and routine tasks, it is possible that vital information will
be missed.16
This was controversial as nurses insisted that recording
this information proved that the nurse had performed the
necessary tasks. A common example given to researchers
was that many nurses had encountered relatives who com-
plained that the patient had not been showered. The
nursing documentation was used to reassure relatives that
this task had been performed. We pointed out to nurses
that other tasks, such as ensuring the patient had eaten,
was not routinely recorded in the nursing notes, even
though relatives often complained that this aspect of care
was neglected. Other avenues, such as signing for routine
tasks on the nursing care plan which is separate entity in
the healthcare record, can be used to demonstrate that
these particular routine tasks have been attended.
Nurses were asked to document the patient’s condition and the
care given to the patient contemporaneously or as events occurred.
Traditionally, nurses completed their documentation
at the end of a shift. The policy developed from this
research required that they document the patient’s con-
dition and their care as it occurred to ensure that nursing
documentation was an accurate reflection of events. It can
be very difficult to reconstruct events at a later time
and further confusion can be caused by subsequent
events.54
Continuity of care increases our opportunities to deliver logical,
sequential and problem-based approaches to documentation.
The lack of continuity of care in our patient allocation,
and to a lesser extent our team nursing models of care
delivery, allow for disconnection of the nurse from the
patient at regular intervals. Our medical colleagues are
more likely to have the same caseload until discharge. As
nursing interventions might take time to be effective or
indeed might be effective quickly such as pain relief, it is
difficult to present a logical record, which presents a
problem (defined by Nurse A) and describes the interven-
tion (defined by Nurse A), with no outcome noted only
expected. Nurse C cares for the patient that evening and
the patient has recovered with the intervention of Nurse
A, but it is unlikely that Nurse C will note the outcome of
Nurse A’s defined problem. The nature of care delivery
models go some way to interfere with our ability to
deliver logical, sequential and problem-based content.
The caseload models of care delivery are more likely to
support such documentation approaches. Other writers
have also identified the importance of written documen-
tation relative to models of care.62
In conclusion, as key writers have identified, the first
critical issue is to encourage nurses to value the written
communication of their nursing care so that it provides an
effective space to define and evaluate professional nursing
practice. The policy has delivered seven essentials of
quality nursing documentation predicated on a review of
contemporary literature and local policies. Some new and
some existing, but not implemented principles, were
uncovered. This policy represented a significant change in
practice for many nurses in our health service. The imple-
mentation of these essentials through education and audit
remains in progress and will be reported at a later date.
Initial barriers have been identified.
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