Documentation practices of nurses in long-term care.
Documentation of nursing care is an important source of reference and communication between nurses and other health care providers. This article describes a study of the documentation practices of nurses in a long-term care institution. Results revealed a number of positive aspects of nurses' documentation practices and areas requiring modification or change which could be facilitated through redesigning the documentation system. Implications for professional practice are discussed, which include the need for a concise, non-duplicating system of documentation, and the importance of nursing documentation in support of evidence-based practice.
Martin
A
A
Nursing Services, Sisters of Charity of Ottawa Health Service, Ontario, Canada.
Hinds
C
C
Felix
M
M
D000368:Aged; D001291:Attitude of Health Personnel; D004282:Documentation; D019317:Evidence-Based Medicine; D005260:Female; D005851:Geriatric Nursing / Q000379:methods*; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008134:Long-Term Care / Q000379:methods*; D008297:Male; D008501:Medical Records, Problem-Oriented; D020380:Needs Assessment; D015403:Nursing Evaluation Research; D009737:Nursing Records; D009740:Nursing Staff / Q000193:education* / Q000523:psychology*; D010347:Patient Care Planning; D012866:Skilled Nursing Facilities; D011795:Surveys and Questionnaires