Comparison of nurses' and physicians' documentation of functional abilities of older patients in acute care--patient records compared with standardized assessment.
OBJECTIVE
To compare nurses' and physicians' documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries.


METHODS
158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS-AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland.


RESULTS
Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40-60% of the nurses' reports and 80-97% of the physician's reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85-96% by the physicians. Cognitive function was recorded in only 30-40% of the cases.


CONCLUSIONS
The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS-AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care.
Sóltún Nursing Home, Reykjavík, Iceland. annabirna@soltun.is
Anna-Birna
AB
Jensdóttir
Pálmi
P
Jónsson
Anja
A
Noro
Elisabeth
E
Jonsén
Gunnar
G
Ljunggren
Harriet
H
Finne-Soveri
Marianne
M
Schroll
Else
E
Grue
Jan
J
Björnsson
D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D003422:Critical Care; D003625:Data Collection / Q000379:methods; D004282:Documentation / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D005387:Finland; D016330:Frail Elderly; D006801:Humans; D007055:Iceland; D008297:Male; D008499:Medical Records; D008505:Medical Staff, Hospital; D009736:Nursing Process; D010820:Physicians; D011795:Surveys and Questionnaires