Health Informatics Research Laboratory, School of Information Systems and Technology, Faculty of Informatics, University of Wollongong, Australia.
Int J Med Inform. 2013 Sep;82(9):789-97. doi: 10.1016/j.ijmedinf.2013.05.002. Epub 2013 Jun 17.
To describe nursing assessment documentation practices in aged care organizations and to evaluate the quality of electronic versus paper-based documentation of nursing assessment.
This was a retrospective nursing documentation audit study. Study samples were 2299 paper-based and 6997 electronic resident assessment forms contained in 159 paper-based and 249 electronic resident nursing records, respectively, from three aged care organizations. The practice of nursing assessment documentation in participating aged care homes was described. Three attributes of quality of nursing assessment documentation were evaluated: format and structure, process, and content by seven measures: quantity, completeness, timeliness comprehensiveness, frequencies of documentation specific to care domains and data items, and whether assessment forms were signed and dated.
Varying practice in documentation of nursing assessment was found among different aged care organizations and homes. Electronic resident records contained higher numbers and more comprehensive resident assessment forms than paper-based records. The frequency of documentation was higher in electronic than in paper-based records in relation to most care domains. There was no difference between the two types of documentation systems on other aspects of nursing assessment documentation (overall completeness and timeliness, variation of frequencies among different care domains, and item completion in personal hygiene assessment forms).
Electronic nursing documentation systems could improve the quality of documentation structure and format, process and content in the aspects of quantity, comprehensiveness and signing and dating of assessment forms. Further studies are needed to understand the factors leading to the variations of practice and the limitations of nursing assessment documentation and to evaluate documentation quality from a clinical perspective.
描述老年护理机构中的护理评估文档记录实践，并评估电子文档与纸质文档在护理评估记录方面的质量。
这是一项回顾性护理文档审核研究。研究样本包括来自三个老年护理机构的 159 份纸质和 249 份电子居民护理记录中的 2299 份纸质和 6997 份电子居民评估表。描述了参与老年护理院的护理评估文档记录实践。通过七个指标评估护理评估文档记录质量的三个属性：格式和结构、过程和内容：数量、完整性、及时性、全面性、特定于护理领域和数据项的文档记录频率，以及评估表是否签字和注明日期。
不同的老年护理机构和养老院在护理评估文档记录方面存在不同的做法。电子居民记录包含比纸质记录更多和更全面的居民评估表。与大多数护理领域相比，电子记录在文档记录频率方面高于纸质记录。在护理评估文档记录的其他方面（总体完整性和及时性、不同护理领域的频率变化以及个人卫生评估表中的项目完成情况），两种文档系统之间没有差异。
电子护理文档系统可以提高文档结构和格式、流程和内容的质量，在数量、全面性和评估表的签字和注明日期方面。需要进一步研究以了解导致实践差异的因素以及护理评估文档记录的局限性，并从临床角度评估文档质量。
