“Does Nursing Documentation Reflect Actual Work Done by the Nurse? ” Using a multiple-cases method of qualitative research, Brooks (1998) conducted a pilot study to investigate nurses’ perceptions of the function and value of documentation and barriers to this process. The study consisted of interviewing seven staff nurses using open-ended questionnaire that focused on their communication about clinical care and their reasoning and decision making for a client they care of for that day.
Following the interview, the nurses’ comments were compared to the actual documentation on the clients’ charts and the nurses were asked to consider the difference between the actual “nurse work” and the documented data. The data were categorized according to content, which helped identify themes. All of nurses stated that they valued documentation; however, they felt a hopelessness about the use of the nurses’ notes (e. g, “a lot of things we write are not that important”). Barriers to documentation included workload demands and cumbersome charting format.
The nurses implied that they did not have the language or motivation to chart about behaviors of nonphysical concerns of the client. Discrepancies were found between the nursing issues verbalized by the nurses and the documented data. The nurses verbalized how they spent time with their clients on such issues as preoperative anxiety and determining if a clients’ confusion was new or old. They freely discussed their intuitive judgments and clients’ emotions by describing their perceptions of the clients’ situations (e. . , “he needs to talk things out”).
The nurses developed strategies that the passed along verbally at the change-of-shift report (e. g. , “you need to spend time with him”). The documentation, however, reflected a medical model of primarily physical assessment data. Most of the nurses were surprised by the incongruency between what they said was important and what they documented. Implications: This pilot study suggests that nurses do not clearly document their knowledge and practice issues.
Client behavioral issues were considered important but were verbally communicated rather than documented in the chart. If nursing documentation does not accurately reflect actual work done, nurses are minimizing their contribution to health care. With care-managed health care, it is vitally important that nurses communicate their knowledge and care strategies. Nurses need to present their unique and holistic approach to client care in the clients’ record.