[Quality dimensions in patient records--a standardised analysis of nursing home resident records].
279 resident records of 26 nursing homes were analysed using a standardised instrument as part of a comprehensive study about the quality of nursing homes in Frankfurt on Main. The main questions referred to the completeness of several content indicators and the visibility of the nursing process in the different parts of the records. Selection criteria were records only of residents in care dependency level two or three. From each of the 26 participating nursing homes at least 10 up to a maximum of 14 records depending on the number of residents were chosen. The best part of the documentation is the assessment, especially the body-oriented problems and resources and the caring devices. However neither the resident's perspective or the source of information are generally noted. The planning part contains mainly interventions, is not always related to the assessment and refers quite seldom to the support of resources. The report shows even more deficiencies. The worst part is the evaluation. A comparison of extreme groups of nursing homes with a very good resident/staff relationship to those with a very bad resident/staff relationship shows that many parts of the records, but not all, are much better documented in the homes with more staff than in those with less staff.
Universität Witten/Herdecke, Institut für Pflegewissenschaft und Fachhochschule Frankfurt am Main, Studiengang Pflege.
Sabine
S
Bartholomeyczik
Maria
M
Morgenstern
D000368:Aged; D002908:Chronic Disease / Q000451:nursing*; D004282:Documentation / Q000592:standards; D005858:Germany; D006707:Homes for the Aged / Q000592:standards*; D006801:Humans; D009723:Nurse-Patient Relations; D009730:Nursing Assessment / Q000592:standards; D009735:Nursing Homes / Q000592:standards*; D009736:Nursing Process / Q000592:standards; D009737:Nursing Records / Q000592:standards*; D015399:Nursing Research; D011785:Quality Assurance, Health Care / Q000592:standards*