Adequate documentation in nursing is a crucial task, as it gives practitioners the chance to provide quality care to their patients. However, although it is an essential procedure, it is not easy to achieve it and is accompanied by many challenges. With that in mind, this piece focuses on why proper documentation fails in nursing practice, its consequences, and possible remedies. This paper is centered on the thesis that poor nursing documentation is a prevalent issue that seriously affects patient care. Mitigating or fully addressing the problem and its causes requires urgent interventions.
Factors Contributing to Inadequate Documentation
The nursing profession is demanding, and practitioners often serve many patients. As a result, being overwhelmed is not unusual, as illustrated by Kamil et al. (2018), who discussed how understaffing and limited resources can affect patient outcomes. This high workload can deny nurses enough time to record patient data as they are obligated to prioritize patient care, leading to incomplete documentation. Aside from time constraints, the absence of a standardized data recording system makes it problematic to have a consistent information flow and ensure accuracy. As of right now, there are no established standards worldwide. Accordingly, it is not always feasible in practice to have continuous information availability and accurate patient health monitoring, as noted by Tuti et al. (2016).
Electronic Health Records (EHRs) are useful pieces of technology that can streamline and improve the documentation process. Despite their practicality, their usage and implementation are associated with hurdles, including a lack of proficiency by users, unfriendly user interfaces, and insufficient training. These factors, as Ting et al. (2021) point out, hinder nurses’ capacity to successfully use technology, resulting in inadequate or incorrect electronic recordings.
Impacts on Patient Care and Healthcare Delivery
Documentation heavily influences healthcare delivery and patient outcomes. Failure to record adequate patient information may cause decision-making challenges in areas such as resource allocation and diagnosis (Tuti et al., 2016). Another important effect of poor documentation is the likelihood of the occurrence of medical errors in healthcare environments. Additionally, with improper documentation, there is also a possibility of communication problems among clinicians.Bunting and de Klerk’s (2021) definition of clinical documentation is the “process of creating a written, electronic record that describes a patient’s history and the care given to a patient” (1). So, in the event that this process fails to capture patient information correctly, other providers involved in a patient’s care delivery are left without a clear picture of the patient’s history, current condition, and treatment plan. As a result, the risk of medical mistakes grows. The situation also undermines the continuity of care.
Like any other field, the medical industry is subject to defined laws. However, with inadequate documentation, the industry risks legal and regulatory problems. Proper documentation is crucial in healthcare operations as it acts as a legal record of the services institutions and clinicians provide. But, as Kamil et al. (2018) argue, records that do not meet the requisite standards might have legal consequences for healthcare professionals and organizations. Legal issues undermine the healthcare system’s trust and accountability.
Finally, nursing documentation, via quality improvement initiatives, is critical in raising the standard of care. It is essential for evaluating, keeping track of, and raising healthcare standards. But as Bjerkan et al. (2021) demonstrate, there are several significant barriers, such as inadequate training, poorly defined processes, underutilized technology, and convoluted records. When combined, they make it more challenging to use nurse documentation in quality improvement programs. Thus, tailored efforts are required to overcome these systemic hurdles.
Solutions and Best Practices
Developing a multifaceted approach to the problem is the most effective method to tackle the issues raised by inadequate nursing documentation. Arguably, one of the most important approaches would be for more standardized documentation to occur. Tuti et al. (2016) assert that standardizing documentation tools and procedures is essential to raising the quality and dependability of clinical data used in research and patient care. This occurrence is because, with standardization, inconsistencies in documentation processes are mitigated, guaranteeing that all patient information is dependably and comprehensively recorded.
Proper training is always important for guaranteeing quality service delivery in every field, and nursing is no exception. It is also paramount to ensure that the staff education and training programs are sustainable. Organizations should be able to fund these capacity development initiatives continually without posing a threat to future success and the achievement of set goals. The importance of training and education for healthcare professionals cannot be emphasized enough, especially with the recent technological changes happening in healthcare. For nursing staff, ongoing education and assistance are essential for the professionals to become better qualified to handle the intricacies of Electronic Health Records (EHR) systems (Ting et al., 2021). The professionals may be engaged in capacity-building activities that enhance their knowledge and skills in ways that lead to the effective utilization of EHRs and the management of technological issues affecting the delivery of quality healthcare services. When education and training have been done perfectly, a healthcare organization will most likely experience improvements in the ways patient data is handled and healthcare services are delivered.
Technology can also be leveraged to streamline the documentation process. For example, Bunting and de Klerk (2021) mention the use of digital scribes that could translate clinical encounters into meaningful and accurate records by leveraging “advances in speech recognition, natural language processing, artificial intelligence, machine learning, and clinical decision support technologies” (p. 7). In addition to such technologies, improved EHR systems with more intuitive interfaces and supportive documentation features would significantly reduce the time and effort required for documentation. Nurses could also easily maintain detailed records without losing the focus on patient care.
Finally, nursing teams must develop an accountability and collaboration culture. As recommended by Tuti et al. (2016), this kind of culture helps improve documentation. Thus, practitioners should establish an atmosphere of openness, peer assistance, and regular feedback on their documentation practices to identify areas for improvement and promote adherence to documentation standards.
This analysis highlights how crucial accurate and extensive nursing assessment documentation is for high-quality patient and healthcare provision. Time constraints, lack of process, inadequate training, and technical barriers are factors that inhibit successful nursing documentation methods. The identified solutions for the above-said challenges are established and standardized documentation systems, extensive training for all the people involved in the process, technology utilization, and fostering a responsible culture. It has been established that nursing documentation plays a critical role in ensuring the quality of patient care, practitioner communication, and overall healthcare delivery. Therefore, it is essential to improve nursing documentation practice for the betterment of healthcare.
References
Bjerkan, J., Valderaune, V., & Olsen, R. M. (2021). Patient safety through nursing documentation: Barriers identified by healthcare professionals and students. Frontiers in Computer Science, 3(1), 1–11. https://doi.org/10.3389/fcomp.2021.624555
Bunting, J., & de Klerk, M. (2021). Strategies to improve compliance with clinical nursing documentation guidelines in the acute hospital setting: A systematic review and analysis. SAGE Open Nursing, 8, 1–34. https://doi.org/10.1177/23779608221075165
Kamil, H., Rachmah, R., & Wardani, E. (2018). What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences, 9, 111–114. https://doi.org/10.1016/j.ijans.2018.09.002
Ting, J., Garnett, A., & Donelle, L. (2021). Nursing education and training on electronic health record systems: An integrative review. Nurse Education in Practice, 55. https://doi.org/10.1016/j.nepr.2021.103168
Tuti, T., Bitok, M., Malla, L., Paton, C., Muinga, N., Gathara, D., Gachau, S., Mbevi, G., Nyachiro, W., Ogero, M., Julius, T., Irimu, G., & English, M. (2016). Improving documentation of clinical care within a clinical information network: an essential initial step in efforts to understand and improve care in Kenyan hospitals. BMJ Global Health, 1, 1-8. https://doi.org/10.1136/bmjgh-2016-000028
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