title: Nursing documentation in long-term care settings: New empirical evidence demands changes be made.
abstract: In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above (N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident-nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses' work overload.
authors: Faculty of Nursing Sciences, Laval University, Quebec City, QC, Canada Centre for Excellence in Aging-Research Unit, Quebec City, QC, Canada philippe.voyer@fsi.ulaval.ca.
authors: Philippe
authors: P
authors: Voyer
authors: St. Mary's Research Centre, Montreal, QC, Canada Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
authors: Jane
authors: J
authors: McCusker
authors: Department of Psychiatry, St Mary's Hospital, Montreal, QC, Canada Department of Psychiatry, McGill University, Montreal, QC, Canada.
authors: Martin G
authors: MG
authors: Cole
authors: Division of Geriatric Medicine, Jewish General Hospital, Canada Donald Berman Maimonides Geriatric Center, Canada.
authors: Johanne
authors: J
authors: Monette
authors: Institut Universitaire de Gériatrie de Montréal, Département de Médecine Familiale, Université de Montréal, QC, Canada.
authors: Nathalie
authors: N
authors: Champoux
authors: St. Mary's Research Centre, Montreal, QC, Canada Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
authors: Antonio
authors: A
authors: Ciampi
authors: St. Mary's Research Centre, Montreal, QC, Canada.
authors: Eric
authors: E
authors: Belzile
authors: Division of Geriatric Medicine, Centre Hospitalier de l'Université de Montréal and Department of Medicine, Université de Montréal, Montreal, QC, Canada.
authors: Minh
authors: M
authors: Vu
authors: Centre for Excellence in Aging-Research Unit, Quebec City, QC, Canada.
authors: Sylvie
authors: S
authors: Richard
mesh_terms: D000368:Aged; D003693:Delirium / Q000451:nursing; D036262:Empirical Research; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration; D009730:Nursing Assessment; D009735:Nursing Homes / Q000458:organization & administration*; D009737:Nursing Records; D011792:Quebec
keywords: delirium; long-term care setting; nursing documentation