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Nursing Notes Examples: A Guide to Effective Documentation

Nursing Notes Examples – Nursing notes are an integral part of patient care. They serve as a vital communication tool between healthcare professionals, ensuring that everyone involved in a patient’s treatment is well-informed. In this article, we will explore the significance of nursing notes, their key components, and the best practices for documenting patient information effectively.

Table of Contents

Why Are Nursing Notes Important?

Nursing notes are essential for several reasons:

• Communication : They facilitate communication among healthcare providers, helping the medical team understand the patient’s condition and progress.
• Legal Documentation : Nursing notes can serve as legal evidence in the event of medical disputes, providing a clear record of patient care.
• Continuity of Care : They ensure that multiple healthcare professionals involved in a patient’s treatment can pick up where the last left off.
• Quality Care : Effective documentation leads to better patient care, as it aids in the assessment and management of the patient’s condition.

Components and Structure of Nursing Notes

Nursing notes are structured documents that follow a standardized format. Here is a breakdown of the typical components that make up a nursing note:

• The header contains the patient’s demographic information, including their name, medical record number, date of birth, and contact information.

Date and Time

• This section records the date and time when the nursing note is written. It is crucial to maintain a chronological record of the patient’s care.

Subjective Data

• Subjective data includes information provided by the patient or their family, such as their description of symptoms, pain level, or concerns.

Objective Data

• Objective data is the nurse’s direct observations and measurements. This can include vital signs, physical assessments , laboratory results, and any other quantifiable data.
• The assessment section is where the nurse provides their professional judgment of the patient’s condition. This includes identifying potential issues or changes in the patient’s health.
• The plan outlines the nursing interventions that will be undertaken to address the patient’s needs and concerns. It includes medications, treatments, and any changes in the care plan.
• The evaluation is a critical section where the nurse reflects on the effectiveness of the interventions and the patient’s response to treatment.
• The nursing note is always signed and dated by the nurse, confirming their responsibility for its content.

Crafting Detailed Nursing Notes

Nursing notes examples.

Now, let’s explore some nursing notes examples to provide you with a clear understanding of how to create effective and comprehensive nursing notes. These examples are structured according to the SOAP (Subjective, Objective, Assessment, Plan) format, which is commonly used in healthcare documentation.

Nursing Notes Example: General Assessment

Subjective: The patient reports mild to moderate abdominal pain, localized in the lower right quadrant. He rates the pain as 6 out of 10.

Objective: Vital signs stable, with blood pressure 120/80, heart rate 80, and respiratory rate 16. The abdomen is tender to palpation in the right lower quadrant. No guarding or rebound tenderness.

Assessment: Likely acute appendicitis. Pain is a concern.

Plan: Notify the physician for evaluation. Administer IV fluids and NPO (nothing by mouth) status in preparation for possible surgery.

Nursing Notes Example: Postoperative Care

Subjective: The patient is groggy and reports pain at the surgical site. Pain is rated as 8 out of 10.

Objective: Vital signs stable, with blood pressure 130/90, heart rate 92, and respiratory rate 18. Dressing over surgical site intact. Minimal serous drainage noted.

Assessment: Immediate post-op period. Pain management is a priority.

Plan: Administer prescribed pain medication as needed. Monitor the surgical site for any signs of infection or complications.

The Importance of Clear and Concise Language

Using clear and concise language is crucial when documenting nursing notes. Avoid jargon and acronyms that may not be universally understood. The notes should be comprehensible to anyone reading them, including patients.

Electronic Health Records (EHRs) and Nursing Notes

Electronic Health Records (EHRs) have transformed the way nursing notes are recorded. They provide a secure and easily accessible platform for documenting patient information. Nurses can now input data directly into EHRs, improving accuracy and efficiency.

Legal Implications

Nurses should be aware of the legal implications of nursing notes. Inaccurate or incomplete documentation can have serious consequences, including legal action. Always document facts, avoid speculation, and never alter records.

Common Mistakes to Avoid

Some common mistakes in nursing documentation include illegible handwriting, skipping sections, or failing to sign entries. Nurses should take care to avoid these errors to maintain the integrity of the patient’s medical record.

Tips for Effective Documentation

To ensure effective documentation, nurses should:

• Document in real-time or shortly after an event.
• Use objective and descriptive language.
• Sign and date each entry.
• Avoid leaving blank spaces or drawing lines for future entries.

Nursing Notes and Interdisciplinary Communication

Nursing notes are not exclusive to nurses; they serve as a communication bridge with other healthcare professionals. It’s essential to share pertinent information with the entire healthcare team to ensure comprehensive patient care.

In Nursing Notes Examples conclusion, nursing notes play a vital role in patient care and healthcare communication. Clear, accurate, and timely documentation is essential to provide quality care, protect legal interests, and maintain a record of a patient’s journey to recovery.

Are nursing notes only for in-patient care?

No, nursing notes are essential for all patient care settings, including hospitals, clinics, long-term care facilities, and home healthcare.

How often should nursing notes be updated?

Nursing notes should be updated regularly, especially when there is a significant change in the patient’s condition or when interventions are performed.

Can patients access their nursing notes?

In many healthcare systems, patients have the right to access their medical records, including nursing notes. However, this may vary by location and facility.

Please note that this article is for informational purposes only and should not substitute professional medical advice.

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In this section

Nursing Documentation Principles

Introduction

Nursing documentation is essential for clinical communication. Documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to support the multidisciplinary team to deliver individualised care. Documentation provides evidence of care and is an important professional and medico legal requirement of nursing practice. 

To provide a structured and standardised approach to nursing documentation for inpatients. This will ensure consistent clinical communication processes across the RCH.

Definition of Terms

• EMR : electronic medical record
• EMR Review : process of working through the EMR activities to collect pertinent patient details.
• The Hub: presents a timeline view of the orders, events, and requirements for each patient the nurse is assigned to and facilitates efficient documentation.
• Real time : nursing documentation entered in a timely manner throughout the shift.
• Required documentation : minimum documentation required to reflect safe patient care. On admission and at the commencement of each shift, all ‘required documentation’ must be completed to comply with the National Safety & Quality Health Service Standards . There is an expectation that shift required documentation is completed within 3 hours of shift start time.

Nursing documentation is aligned with the ‘nursing process’ and reflects the principles of assessment, planning, implementation and evaluation. It is continuous and nursing documentation should reflect this.

Fig 1. Nursing Process

Please note nursing process theory referenced includes an additional phase ‘diagnosis’ which includes identification of problems, risk factors and data analysis, for the purpose of the Nursing Documentation guideline ‘diagnosis’ could occur at any phase and should be documented in real time. 

Reference Fig 1: Nursing Theory, the Nursing Process The Nursing Process - Nursing Theory (nursing-theory.org) accessed 2/2/2023

At the beginning of each shift, a ‘primary assessment’ is completed as outlined in the Nursing Assessment Guideline . The information for this assessment is gathered from bedside handover, patient introductions, required documentation (safety checks and risk assessments, clinical observations) and an EMR review and is documented in relevant the ‘Flowsheets’.

Review of the EMR gives an overview of the patient. To complete an EMR review, enter the patients’ medical record and work through the key activities in order. The Patient storyboard has a significant information which can be viewed by hovering over sections. The tabs across can be customised to meet the specific needs of your patient group ( EMR learning resources ). It is recommended that each ward standardises the layout based on their patient population.

The EMR review should include (*indicates essential);

• *Patient storyboard - age, treating team, FYIs, infections, allergies, isolations, LOS, weight
• *IP Summary - Medical problem list, treatment team, orders to be acknowledged
• *ViCTOR Graph - observations trends, zone breaches
• *Notes - e.g. admission, ward round, any other useful details (mark all as not new)
• *Results Review - recent and pending results (time mark)
• *MAR - overdue medications, discontinued, adjust due times for medications
• Fluid Balance- input/output and balance
• Avatar- review lines/drains/airways/wounds, including, location, size, date inserted
• review all active, continuous, PRN and scheduled, discontinue expired,
• nursing orders create and manage as required for patient care  
• Flowsheets - document specific information, ‘last filed’ will show most recent entries, review and manage unnecessary rows e.g. ‘complete’

Patient details are documented in the relevant flowsheets and must include the minimum ‘required documentation’. To ensure required documentation for each patient is complete, use the links from the Hub or other sections of EMR ( EMR learning resources ). 

With the information gathered from the start of shift assessment, the plan of care can be developed in collaboration with the patient and family/carers to ensure clear expectations of care.

The Hub is a shift planning tool and provides a timeline view of the plan of care including, ongoing assessments, diagnostic tests, appointments, scheduled medications, procedures and tasks. The orders will populate the hub and nurses can document directly from the hub into Flowsheets in real-time. Orders are visible by the multidisciplinary team. 

Management of orders is crucial to the set up and useability of the hub. It must be ‘cleaned up’ before handover takes place - too many outstanding orders is a risk to patient safety.

For more information on how to place and manage orders, click on the following tip sheet: Nursing Hub.

Additional tasks can be added to the hub by nurses as reminders. All patient documentation can be entered into Flowsheets (observations, fluid balance, LDA assessment) throughout the shift. 

Nursing staff can also document patient care in narrators or navigators as appropriate i.e. ATD navigators. 

Clinical information that is not recorded within flowsheets, narrators or navigators and any changes to the plan of care is documented as a real time progress note.

This may include:

• Abnormal assessment, e.g. Uncontrolled pain, tachycardic, increased WOB, poor perfusion, hypotensive, febrile etc.
• Change in clinical state, e.g. Deterioration, improvements, neurological status, desaturation, etc.
• Adverse findings or events, e.g. IV painful, inflamed or leaking requiring removal, vomiting, rash, incontinence, fall, pressure injury; wound infection, drain losses, electrolyte imbalance, +/-fluid balance etc.
• Patient outcomes after interventions e.g. Dressing changes, pain management, mobilisation, hygiene, overall improvements, responses to care etc.
• Family centred care e.g. Parent level of understanding, participation in care, child-family interactions, welfare issues, visiting arrangements etc.
• Social issues e.g. Accommodation, travel, financial, legal etc.

Implement and evaluate 

Progress note entries should not simply list tasks or events but provide information about what occurred, consider why and include details of the impact, outcome and plan for the patient and family.

All entries should be accurate and relevant to the individual patient - non-specific information such as ‘ongoing management’ is not useful.

Duplication should be avoided - statements about information recorded in other activities on the EMR are not useful, for example, ‘medications given as per MAR’.

Professional nursing language should be used for all entries - abbreviations should be used minimally and must be consistent with RCH standards, for example, ‘emotional support was provided to child family’ could be documented instead of ‘TLC was given’. See Medical Acronyms and abbreviations list.

Real time notes should be signed off after the first entry and subsequent entries are entered as addendums.

Example of real time progress note entry:

09:40 NURSING. Billie is describing increasing pain in left leg. FLACC 7/10. Paracetamol given; heat pack applied with some effect. Education given to Mum at the bedside on utilising heat pack in conjunction with regular analgesia. Continue pain score with observations. (Progress Note, sign at the end)

10:15 NURSING. Episode of urinary incontinence. Billie quite embarrassed. Urine bottle given. (Addendum)

14:30 NURSING. Routine bloods for IV therapy taken, lab called- high K+ (? Haemolysed). Medical staff notified, repeat bloods in 6/24. Encourage oral fluids and diet, if tolerated. IV can be removed. (Addendum)  

Companion Documents

• National Safety & Quality Health Service Standards
• Nursing Assessment Guideline
• Patient Identification Procedure 
• EMR Learning Resources
• Medical Acronyms and abbreviations list.

Evidence Table

The evidence table for this guideline can be viewed here. -- Coming soon

 Please remember to read the disclaimer . 

The revision of this nursing guideline was coordinated by Stacey Richards, CNC, Nursing Research and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.  

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Nursing Documentation Examples and Tips

by Cindy Wong | Sep 19, 2022 | Blog | 0 comments

Keeping good nursing records is essential, as it ensures a high standard of care is provided to residents while also acting as proof of care should any lawsuits occur. One of the best ways to ensure that nurses follow best documentation practices is to use effective nursing documentation examples to help get them prepared for real-life scenarios. 

Most facilities have their own policies and procedures regarding how nurses document care, including who received care (resident), when the care took place (date), what treatment took place, and who administered the therapy (signature). Facilities will often provide their own nursing documentation examples to newly hired nurses, so they understand and document care using the facility’s standardized format, making it easier for all staff members to be on the same page. 

Here we will provide guidelines about nursing documentation, what is to be included, how to avoid pitfalls, and the best resources available for improving your process. 

What Type of Resident Information Is Documented?

While nursing documentation may slightly differ according to the state and facility, most will document the following clinical nursing documentation data :

• Resident assessments
• Vital signs
• Changes to residents’ weight and height
• Type of medication and administration
• Intravenous and blood product therapy
• Nurse’s notes
• Physician orders and accompanying notes
• Therapy notes

Facilities prefer to use long term care EHR systems over handwritten notes, as they allow for more accurate documentation and improved workflow efficiency. Also, all resident data included in long term care software is readily available when needed. 

Of course, in the case of a computer system failure , nurses must return to relying upon handwritten documentation to detail the essential facts in concise sentences, though they are later transferred to the long term care EHR system once it is up and running again. 

In addition to documenting the clinical notes mentioned above, long term care facilities must also include daily nursing notes that are specific to Skilled Nursing Facilities (SNFs), such as:

• System assessments, 
• Activities of Daily Living (ADLs)
• Changes in residents’ condition
• Resident attendance and response to therapy (physical, occupational, and speech)  

What Are the Regulations of Nursing Documentation?

According to the American Nurses Association (ANA) standards of nursing practice , nursing documentation notes should follow each state’s requirements according to the Nursing Practice Act (NPA), which defines safe and competent nursing practices. While the NPA may differ according to each state, the general requirements for how nursing notes are that they should be:  

• Objective and not critical or subjective
• Clear, concise, and comprehensive
• Accurate, truthful, and honest even if an incident or error occurs
• Representative of observations rather than guesswork
• In accordance with state laws, forms, methods, systems, standards, and facility policies

Nursing notes must also include: 

• The nurse’s response to the care and actions taken
• A complete record of all nursing care and treatment must be documented, detailing all assessments, health issues, personalized care plan, actionable treatments, and evaluation
• All relevant nursing documentation 

Failure to follow these guidelines can result in documentation errors that subsequently lead to adverse medical errors. Hence, facilities should provide adequate nursing documentation training to mitigate these errors. 

Common Nurse Charting Errors

For healthcare providers, accurate nurse charting documentation can be the difference between life and death. Therefore, facilities must provide nursing documentation examples so that nurses can understand what is expected of them. For example, in Texas, facilities offer nurse charting training by detailing: the federal and state laws to which they must adhere; facility standards and rules; common errors and ways to improve documentation; and sample nurse notes used for training purposes.

Contrary to the popular belief that documentation errors occur because nurses are incompetent or reckless, nurse charting errors often arise because nurses do not receive adequate Electronic Medical Records (EMR) or EHR training. In addition, faulty systems and fragmented facility processes can further exacerbate charting errors, resulting in inaccurate data entries. 

Therefore, rather than blaming nurses, facilities must address their failed processes before finding appropriate solutions to improve their training procedures. Some examples of the most common nurse charting documentation errors are:

• Illegible handwritten nursing notes: These can lead to mixed messages regarding a resident’s medical history or care, for example, charting “hyper” instead of “hypo.”
• Failure to capture important entry details : Failing to document important nursing notes like the date, time, and medical entry signature can lead to medical errors and serious consequences. 
• Lack of documentation: Nurses must document all previous medications or treatments administered within the facility and by other healthcare providers. Failure to do so is another way to cause medical errors. 
• Incomplete or missing documentation: Clinicians need to know each resident’s complete medical history to make informed medical decisions based on data rather than guesswork.
• Not adding entries during the point of care: If nurses do not enter or update their nursing notes at the point of care (while beside the resident), they may forget specific details, and that can lead to inaccurate data entries. 
• Not documenting care objectively: Nursing notes must be accurate and precise, based on observations and facts and not opinions or guesses. 
• Not questioning inconclusive orders: Despite the best efforts of clinicians, they are human and can make mistakes. If a nurse has any reservations about a specific treatment, they should voice their concerns or risk the facility making medical errors. 
• Incorrect use of abbreviations and acronyms: There are many abbreviations and acronyms in nursing documentation, which can be challenging for a new nurse to keep up with. To help stay on top of things, they can use the Mennonite College of Nursing (MCN) comprehensive list of nursing acronyms and abbreviations , which includes the acronyms accepted all across America.
• Wrong data entries: If nurses are not diligent, they may enter information into the wrong resident chart or care plan. 

Any combination of these nursing charting errors can lead to adverse medical errors, leaving the facility vulnerable to liability and malpractice lawsuits. This is all the more reason why providing relevant EMR and EHR training to nurses is imperative for residents’ health and safety and the facility.  

If you want to learn more about nursing documentation and how long term care software can improve your facility’s processes, contact us here .

6 Nursing Documentation Examples PDF Resources and Tips

Like other healthcare providers, long term care staff work in shifts. Therefore, it is imperative that when a nurse starts a shift, they are confident in the nursing documentation and its accuracy.  With accurate documentation, clinical staff can effectively communicate a resident’s condition to their shift replacement via their care plan. 

Listed below are some tips nurses can use to protect themselves and their facility while also improving the accuracy of their nursing documentation: 

• Prioritize Nursing Documentation Time

A nurse has many responsibilities, and at times, it may seem like they are too busy to document nurse notes. However, they must always prioritize nursing documentation, especially when there are changes in code status, admissions, transfers, verbal orders, abnormal vitals, or even changes in medication. Doing so ensures all critical data is captured accurately. 

• Be Detailed and Specific 

When documenting assessments and notes, nurses should be specific and concise, detailing what, when, where, and why they are documenting a particular treatment. It is best to avoid using general language, as this can lead to unnecessary confusion. If nurses are unsure how to be precise, they can practice activities found in nursing documentation examples PDF workbooks, such as Documentation in Nursing Practice . 

• Know the Facility’s Procedures and Guidelines

Nurses must protect themselves from liability lawsuits, which means they must know the facility’s and state nursing documentation guidelines. Some nursing orientation training handbooks will include detailed nursing documentation examples , with helpful illustrations of completed documentation forms, such as initial and daily assessment forms, which fall within a nurse’s documentation responsibilities. 

• Be Mindful of Allergies 

An often overlooked nurse entry note is the residents’ allergy status . A physician needs this essential information to administer the proper medication, dosage, and treatment.  Therefore, nurses must be mindful when filling out nursing charts to include all adverse allergy reactions and update any new information in the long term care EHR. 

If a nurse is unsure how to document allergies, they can refer to online examples and functions of nursing documentation for more information on how to correctly document care. 

• Nurse Charting Timeline

Nurse charting is very time-specific. It cannot be done in advance and should not be done after the point of care, as either option puts the nurse at risk of entering inaccurate information. Should erroneous information be entered, the nurse must follow facility policies to correct any charts approved by management. 

Efficient nursing home management software will have pre-built assessment templates that help to minimize errors and improve nurse charting accuracy. These valuable tools offer suggested problems and correlations templates so nurses can modify and personalize resident charts accordingly. 

• Use the SBAR Approach

Facilities can encourage their nurses to use the SBAR approach : situation, background, assessment, and recommendation to better set expectations and ensure a resident’s charts are documented correctly in the nursing home software and the best practice steps are followed.

The Advantages of Using Nursing Documentation Examples

Nursing documentation is entered into a facility’s LTC software for accurate and convenient record keeping. The computerized documentation system allows caregivers to process, share, and access relevant information to provide residents safe and quality care. Effective nursing home charting software will also include helpful nursing documentation examples and templates for user-defined assessments so nurses can personalize a resident’s care plan efficiently without needing to sift through paperwork. 

Updating nursing charts electronically via handheld devices connected to the care plan software allows nurses to reduce documentation errors significantly when modifying resident condition changes. It also speeds up the time required to document care, improves accuracy, and legibility.

For more on recent trends in long term care, read our blog and subscribe to the LTC Heroes podcast . 

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Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses

Kim de groot.

1 Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513CR Utrecht, The Netherlands

2 Thebe Wijkverpleging [Home care organization], Lage Witsiebaan 2a, 5042DA, Tilburg, The Netherlands

Anke J. E. De Veer

Anne m. munster.

3 Nursing Science, Programme in Clinical Health Sciences, University Medical Centre Utrecht, PO Box 85500, 3508GA Utrecht, The Netherlands

Anneke L. Francke

4 Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centre and Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands

Wolter Paans

5 Research Group Nursing Diagnostics, School of Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714CA Groningen, The Netherlands

6 Department of Critical Care, University Medical Centre Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands

Associated Data

The data that support the findings of this study are available from the corresponding author upon reasonable request.

The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses’ views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload.

A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman’s rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed.

The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses’ perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records.

Conclusions

Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.

Clinical nursing documentation is essential in letting nurses continuously reflect on their choice of interventions for patients and the effects of their interventions. Therefore, it is vital to the quality and continuity of nursing care [ 1 , 2 ]. Nursing documentation can be described as a reflection of the entire process of providing direct nursing care to patients [ 3 – 5 ]. Consequently, there is international consensus that clinical nursing documentation has to reflect the phases of the nursing process, namely assessment, diagnosis, care planning, implementation of interventions and evaluation of care or – if relevant – handover of care [ 2 , 3 , 6 – 8 ].

Despite the evident importance of nursing documentation, time spent on documentation can be substantial and therefore it can be experienced as onerous for nurses. Research indicates documentation time has reached an extreme form [ 9 – 11 ]. Even though the actual time spent by nurses on documentation varies internationally, it is a substantial part of the work of nurses [ 12 , 13 ]. For example, in Canada nurses spend about 26% of their time on documentation [ 14 ], in Great Britain 17% [ 15 ] and in the USA percentages vary from 25% to as much as 41% [ 16 , 17 ]. In the Netherlands, nursing staff reported spending an average of 10.5 hours a week on documentation [ 18 ], which means they spend about 40% of their time on documentation.

The variation between countries in nurses’ time spent on documentation may be related to differences in electronic health records and the way in which handovers are organized. However, the variation may also be the result of a lack of clarity about what qualifies as documentation [ 19 , 20 ]. Some studies used the term ‘documentation’ for activities that were directly related to individual patient care, e.g. drawing up a care plan or writing progress reports [ 16 , 17 ]. Other studies used ‘documentation’ as an umbrella term that included ‘non-patient-care-related’ documentation as well, such as recording hours worked or recording data for the planning of personnel [ 18 , 20 ].

A conceptual overview from the Organisation for Economic Cooperation and Development (OECD) provides more conceptual clarity in the various types of documentation [ 12 ]. The OECD states that documentation generally can be divided into clinical documentation and documentation regarding organizational and financial issues. Clinical documentation refers to documentation in the electronic health records of individual patients, e.g. about the patient’s medical condition and about the care provided by healthcare professionals. The OECD uses the term ‘organizational documentation’ to refer to the documentation of issues regarding personnel planning and coordinating different shifts, for instance. Documentation such as recording hours worked for the purpose of billing and insurance are categorized by the OECD as financial documentation [ 12 ].

There are indications that organizational and financial documentation in particular has increased in the last decade, which might be explained by the rising demand for accountability and efficiency of care [ 21 ]. Since documenting organizational and financial issues is not directly related to patient care, these aspects of documentation might be perceived negatively by nurses [ 22 ]. In contrast, nurses might be more open to clinical documentation since this documentation is essential to high-quality nursing care [ 1 , 2 , 23 ]. Moreover, according to professional standards and guidelines, clinical documentation should be considered as an integral part of providing nursing care [ 24 – 26 ].

Still, lengthy clinical documentation might be challenging for nurses as well. According to Baumann, Baker [ 27 ], Moore, Tolley [ 28 ] the implementation of electronic health records for individual patients appeared to increase the observed time that nurses spend on clinical documentation. Yet their findings were inconclusive, since long-term follow-up studies indicated decreasing documentation time once nurses became familiar with the electronic health records [ 27 ]. However, other studies indicated that the setup for the electronic health records does not always match nurses’ routines and can therefore be a potential source of perceived time pressure among nurses [ 29 , 30 ]. Yet when the electronic health records follow the phases of the nursing process, this might be supportive for nurses’ clinical documentation [ 31 ].

Nurses’ time pressure and nursing workload have received significant interest, in part because nursing shortages are a problem internationally [ 32 ]. Research often focusses only on the objective nursing workload, measured and expressed in actual time spent caring for a patient and/or staffing ratios [ 33 ]. However, nurses’ emotional or perceived workload might not always correspond to their objective workload [ 34 ]. But the perceived workload of nurses and the related factors is a rather unexplored area. For instance, it was unknown to date if perceived workload is associated with specific types of documentation activities and the actual time spent on these activities.

In line with the above-mentioned conceptual overview from the OECD [ 12 ] and from a nursing perspective, it seems relevant to make a distinction between different types of documentation activities. On the one hand, there is clinical documentation, which directly concerns the nursing care for individual patients. On the other hand, there is organizational and financial documentation; this is documentation that is mainly relevant for care organizations, management, policymakers and/or health insurers. In the Dutch context, clinical documentation often includes care needs assessment information, a care plan structured according to the phases of the nursing process, daily evaluation reports concerning the care given, and the handover of care. Organizational and financial documentation often concerns records of hours worked, expense claims for medical aids, reports on incidents with patients and/or employees, internal audits, and measurements of employee satisfaction and/or patient satisfaction.

To date it was unclear whether specific types of documentation are associated with a high perceived nursing workload. Distinguishing between types of documentation may provide more insight into the possible relationship between documentation and perceived nursing workload.

Furthermore, we used a mixed-methods approach to gain a deeper understanding, with a quantitative survey followed by qualitative focus groups. The quantitative data provided a broad and representative picture of the possible presence of a relationship between perceived workload and documentation activities. However, the reasons why community nurses felt the specific documentation activities increased their workload became clearer from the qualitative data. Combining the findings from these two methods resulted in a credible and in-depth picture of the relationship between documentation activities and perceived nursing workload. This enabled specific recommendations to be made that can help reduce the workload of nurses.

Such insights are relevant in particular for the home-care setting, since a previous survey showed that community nurses reported spending even more time on documentation compared with nurses working in other settings [ 18 ]. In addition, most studies on the documentation burden focus solely on the hospital setting, e.g. the studies of Collins, Couture [ 35 ] and Wisner, Lyndon [ 30 ].

Therefore, the study presented here aimed to gain insight into community nurses’ views on a potential relationship between clinical and organizational documentation and the perceived nursing workload (in this study, ‘organizational documentation’ includes financial documentation). The research questions guiding the present study were:

• (a) Do community nurses perceive a high workload due to clinical and/or organizational documentation? ( survey and focus groups ), (b) If so, is their perceived workload related to the time they spent on clinical and/or organizational documentation? ( survey ).
• Is there a relationship between the extent to which community nurses perceive a high workload and (a) the user-friendliness of electronic health records ( survey and focus groups ), and (b) whether the nursing process is central in the electronic health records ( survey and focus groups )?

A convergent mixed-methods design was used, in which a quantitative survey with qualitative focus groups were combined to develop in-depth understanding of the relationship between documentation activities and perceived nursing workload [ 36 , 37 ]. This design has been proven to be particularly useful for achieving a deep understanding of relationships [ 36 , 38 ]. First, the quantitative survey was performed and findings from this quantitative component were subsequently enriched by the findings of the qualitative focus groups [ 37 , 38 ].

Participants

Survey participants.

The nurses who were sent the online survey were participants drawn from a Dutch nationwide research panel known as the Nursing Staff Panel ( https://www.nivel.nl/en/panel-verpleging-verzorging/nursing-staff-panel ). Members of the Nursing Staff Panel are primarily recruited through a random sample of the population of Dutch healthcare employees provided by two pension funds [ 4 ]. In addition, members are recruited through snowball sampling and open calls on social media. All members had given permission to be approached regularly to answer questions about their experiences in nursing practice. For this study, the survey was sent by email to all 508 community nurses who were members of the Nursing Staff Panel. Since this is a nationwide panel, respondents worked in a variety of organizations across the Netherlands. To increase the response rate, two electronic reminders were sent to nurses who had not yet responded.

This paper focusses on community nurses and electronic nursing documentation; therefore only respondent nurses who met the following criteria were included in the analysis: 1) being a registered nurse with a bachelor’s degree or a secondary vocational qualification in nursing; 2) working in home care; 3) using electronic health records. We excluded 24 respondents who did not meet these criteria.

Focus-groups participants

Focus-group participants were recruited through the professional network of two authors (KdG and AM), open calls on social media (LinkedIn and Facebook), and through snowball sampling. Nurses were eligible to participate in a focus group if they met the same inclusion criteria as used for the survey participants. Purposive sampling was applied to obtain variation among participants regarding the educational level, age and standardized terminology used in the electronic health records. None of the participants of the focus groups had also participated in the survey.

Since the focus groups were in addition to the survey, we expected a priori that four focus groups would be enough to reach data saturation. This expectation was met, as the last focus group produced no new insights that were relevant for answering the research questions.

Data collection

The survey data were collected from June to July 2019. We used an online survey questionnaire that mostly consisted of self-developed questions as, to our knowledge, no instrument was available that included questions on both clinical documentation and organizational documentation. The extent to which nurses perceived a high workload was measured using a five-point scale (1 = ‘never’ to 5 = ‘always’). We distinguished between a high workload due to clinical documentation and a high workload due to organizational documentation. We included financial documentation in our definition of organizational documentation. In the questionnaire we explained the content of the two types of documentation. Respondents were then asked to estimate the time they spent on the two types of documentation.

Next, two questions focussed specifically on clinical documentation, namely whether the electronic health record of individual patients was user-friendly and whether the nursing process was central in this record. These questions were derived from the ‘Nursing Process-Clinical Decision Support Systems Standard’, an internationally accepted and valid standard for guiding the further development of electronic health records [ 31 ].

The entire questionnaire was pre-tested for comprehensibility, clarity and content validity by nine nursing staff members. Based on their comments, the questionnaire was modified, and a final version produced. A translation of the part of the questionnaire with the 11 questions relevant for this paper can be found at: https://documenten.nivel.nl/translated_questionnaire.pdf .

Focus groups

After the survey, we conducted four qualitative focus groups from February to May 2020. Each group consisted of six or eight community nurses, with a total of 28 community nurses. These focus groups were performed in order to deepen and refine the insights gained from the survey data.

The focus groups were led by two authors (KdG and AM) and supported by an interview guide with open questions, see Table  1 . The questions were inspired by the results of the survey data, e.g. they addressed how community nurses perceived clinical and organizational documentation in relation to their workload, or how community nurses experienced the user-friendliness of electronic health records.

Interview guide

Initially, we aimed to conduct all the focus groups face-to-face at the care organizations’ offices. However, after one face-to-face focus group we had to switch to online focus groups due to the COVID-19 pandemic. Online focus groups in which participants post written responses in a secure online discussion site have been proven to be an appropriate alternative for face-to-face focus groups [ 39 – 41 ]. In fact, the online focus groups had several advantages, such as providing participants with the ability to access, read and respond to posts at a place and time most convenient to them [ 40 , 41 ]. This was particularly advantageous for nurses during the pandemic.

Each online focus group was conducted within a set period of 2 weeks. Two authors (KdG and AM) acted as moderators by regularly checking the responses and posting new questions every 2 days, except in the weekend. The analysis of the transcripts has shown that the findings from the online focus groups were comparable to those from the face-to-face focus group.

Data analysis

Analysis of the survey.

Descriptive statistics were used to describe the background characteristics of the respondents and to answer the first and second research questions. Wilcoxon signed-ranked tests were conducted to answer the first research question (1a), since the two variables measuring the perceived workload were ordinal and the two variables measuring the estimated time spent on documentation were not normally distributed. Next, the potential relationships between perceived workload and time spent on documentation (research question 1b) were examined using Spearman’s rank correlations. Wilcoxon rank-sum tests were conducted to examine associations between perceived workload and user-friendliness (research question 2a) and the nursing process (research question 2b). The level for determining statistical significance was 0.05. Analyses were conducted using STATA, version 16.1.

Analysis of the focus groups

The audio recording of the face-to-face focus group was transcribed verbatim. Transcripts from the online focus groups were taken directly from the discussion site.

The focus-group transcripts were analysed using an iterative process of data collection - data analysis - more data collection. Within this process, the six steps of thematic analysis were followed, namely becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting [ 42 ].

The transcripts of all the focus groups were analysed by two authors (KdG and AM). They refined their analyses in discussions together and with two other authors (AF and WP), which ultimate led to consensus about the main themes. This triangulation of researchers was used to increase the quality and trustworthiness of the analysis [ 43 ]. Moreover, ‘peer debriefing’ was applied with a group of peer researchers who were not involved in the study. In addition, confirmability of the findings was enhanced by including verbatim statements made by participants in the results section of this paper. Furthermore, the quality of the reporting was ensured by following the guidelines in ‘Good Reporting of A Mixed Methods Study’ [ 44 ].

Data integration

By integrating data from the quantitative and qualitative components, an in-depth and credible picture was obtained of the relationship between specific documentation activities and perceived nursing workload [ 36 , 37 ]. The data were integrated using two integration approaches. Firstly, we compared the data from the survey and focus groups in the analysis process, in discussions among the authors, and in the ‘ Discussion ’ section of this article. This is referred to as the ‘merging’ approach [ 37 ]. For instance, the survey result on how many nurses perceived a high workload from clinical documentation activities was compared to the focus groups results on nurses’ views as to why they did or did not perceive a high workload from these activities. Secondly, integration through narratives was performed when reporting the results. Hereby we used a ‘weaving’ approach in which we brought the findings from the quantitative survey and qualitative focus groups together on a thematic basis and arranged them according to the research questions [ 37 ].

Ethical considerations

The study was conducted in compliance with the principles of the General Data Protection Regulation, by strictly safeguarding the anonymity of the participants. Formal approval from an ethics committee was not required under the applicable Dutch legislation on medical scientific research as participants were not subjected to procedures and were not required to follow rules of behaviour (see https://english.ccmo.nl/investigators/legal-framework-for-medical-scientific-research/your-research-is-it-subject-to-the-wmo-or-not ).

Participants in the survey had all consented to being sent and completing surveys on a regular basis on topics directly related to their work when they signed up as members of the Nursing Staff Panel. Potential participants of the focus groups were informed about the study in an information letter. If desired, they could obtain additional verbal information. All participants signed an informed consent form before the focus groups started.

All methods were applied in accordance with relevant guidelines and regulations.

A total of 195 community nurses completed the questionnaire (response rate 38.4%). Since a substantial group did not respond, we conducted non-response analyses. We found no statistically significant differences between the respondents and non-respondents regarding gender, level of education and number of hours employed. We did however see a difference in age: the respondents were somewhat older (mean age 49.8 years) than the non-respondents (mean age 44.3 years). We reflect on the relatively high age of the survey respondents in ‘ Limitations and strengths ’ section.

A total of 28 community nurses participated in the four focus groups. The characteristics of the participants are presented in Tables  2 and ​ and3 3 .

Survey participants’ characteristics

# Multiple answers possible

Focus-groups participants’ characteristics

Perceived workload due to documentation and time spent documenting

More than half of the community nurses in the survey said that they perceived a high workload due to clinical and/or organizational documentation, see Table ​ Table4. 4 . A majority (52.4%) said that they regularly to always experienced a high workload due to clinical documentation. Regarding organizational documentation, 58% of the nurses reported a high perceived workload. No statistically significant differences in perceived workload were found between the two types of documentation (Wilcoxon signed-ranked test: p  = 0.124). In other words, nurses were just as likely to experience a high workload due to clinical documentation as due to organizational documentation.

Community nurses’ perceived workload due to documentation and estimated time spent on documentation

Community nurses in the survey estimated that they spent on average 8.0 (SD 6.0; median 6.0) hours a week on clinical documentation. They estimated that they spent significantly less time on organizational documentation, namely on average 3.6 (SD 4.0; median 2.0) hours a week (Wilcoxon signed-ranked test: p  < 0.000).

Looking at clinical documentation, no statistically significant correlation was found between nurses’ estimated time spent on this type of documentation and their perceived high workload (Spearman’s rank correlation 0.135; p  = 0.058). However, looking at organizational documentation, a statistically significant moderate correlation was found between time spent on documentation and perceived high workload (Spearman’s rank correlation 0.375; p  < 0.000). This showed that nurses who spent more time on organizational documentation were more likely to perceive a high workload.

In general, the community nurses participating in the qualitative focus groups experienced a high workload due to documentation as well. They described organizational documentation in particular as cumbersome, redundant and too repetitive in nature. Even though nurses believed that a high workload in general is common among community nurses, they did see documentation as one of the causes for their high workload.

“You are already busy sorting out all the shifts, all the patients who are starting and stopping home care etc. There’s already a high workload. And on top of all that, there are the documentation activities. In our organization, they also want everyone to do refresher courses to keep their registration as a nurse, so you need to register that too. That is another extra documentation burden, and that takes up extra time too.” (Focus group 1, face-to-face).

A general picture that emerged from the focus groups is that organizational documentation was a key reason for community nurses’ perceived workload, while this was less so for clinical documentation. Community nurses in the focus groups said that they often failed to see the added value of organizational documentation for their patients and themselves. Therefore they had a feeling of frustration with the organizational documentation, associated with a high perceived workload.

“I think the frustration comes much more from the organizational side. From powerlessness because of all the pointless things you don’t really have time for.” (Focus group 1, face-to-face).

Focus-group participants mentioned that various rules and regulations imposed by their employers and/or national organizations, such as health insurers, also affected the amount of organizational documentation. They perceived a high workload when they had to register information only for the sake of these rules and regulations.

“Whenever someone in the organization starts talking about reducing the documentation burden, my blood pressure starts to rise. Then I know for certain that it’ll come back in spades some other way: someone else’s documentation burden will be reduced, but not mine.” (Focus group 1, face-to-face).

Community nurses in the focus groups were more positive about their clinical documentation activities. They found clinical documentation necessary and useful for providing good nursing care. For them it was evident that this documentation was an important part of their work. Because they saw clinical documentation as directly connected to individual patient care, they were less negative about the time they had to spend on clinical documentation compared with organizational documentation. Some nurses did however mention that documenting the formal care needs assessment (which is a requirement for home care financed by health insurers in the Netherlands) consumed a lot of their time. Still, nurses did not find this kind of documentation burdensome due to the perceived relevance and usefulness of the documentation of the care needs assessment. This was also the case for clinical documentation relating to individual patient care in general.

“The documentation activities I carry out for my patients are appropriate for my job and the documentation is not an additional burden. On the contrary, that documentation helps me and my fellow nurses to give our patients good, appropriate care.” (Focus group 4, online).

Perceived workload and features of electronic health records

Elaborating further on clinical documentation specifically, we explored the perceived workload in relation to two features of the electronic health records, namely user-friendliness and whether the record matches with the nursing process.

User-friendliness of electronic health records in relation to workload

Most of the community nurses in the survey agreed that the electronic health records in which they documented information about the nursing care for individual patients were user-friendly (78.8%). A smaller group disagreed (17.6%) and a few did not know (3.6%). The survey participants who answered ‘don’t know’ were excluded from the analysis of the association between user-friendliness and the perceived workload. No statistically significant association was found between how often the nurses perceived a high workload and the user-friendliness of electronic health records (Wilcoxon rank-sum test: p  = 0.166), see Table  5 .

Association between perceived workload and the user-friendliness of electronic health records

As for the user-friendliness of electronic health records the opinions and experiences of the community nurses in the qualitative focus groups were divided. While several community nurses were positive about the user-friendliness of the electronic health records, others were less positive. The latter group said that the limited user-friendliness was one reason why they spent so much time on documentation and experienced a high workload. Elaborating on the limited user-friendliness, nurses in the focus groups explained that some mandatory sections or headings in the electronic health records, e.g. about wound care, cost them too much time. They did not always see the added value of filling in those sections, making this a burdensome activity. Furthermore, nurses stated that the fact that they often had to switch between different sections of the electronic health record was time-consuming and burdensome for them as well.

“I also find it a pain that you need to search in different sections for a lot of things. The care plan describes that you have to perform wound care according to the wound policy, but the wound policy itself is under a different heading than the care plan. Then the reports about the wound are under the care plan again. And if the patient also needs help with ADL, you have to go back via the care plan again. It all costs extra time and you have to do a lot of clicking.” (Focus group 3, online).

Focus-group participants also addressed another issue regarding the limited user-friendliness of the electronic health records in relation to their workload. This is the large diversity in electronic systems used within and across care organizations and professionals. For instance, nurses said that they used different systems for documenting wound care and for documenting the medication check. Furthermore, other healthcare professionals, such as general practitioners or pharmacists, often use different electronic systems for their clinical documentation. Community nurses stated that these systems are often not linked to one another, resulting in duplicate documentation activities for nurses and increasing their workload.

“We have at least a dozen systems and only a few are linked to each other. [...] The systems for communicating with other disciplines and medication systems aren’t linked to one another. Despite the positive discussions, you’re still dependent on the preferences of the pharmacist or GP as to what systems are used. That can lead to you having three different medication systems in one team, for example.” (Focus group 4, online).

Nursing process in electronic health records in relation to workload

In the survey, the majority of community nurses agreed that the nursing process was central in their electronic health records (78.7%). Some nurses disagreed (17.2%) and a few did not know (4.2%). To examine a possible association with workload, survey participants who answered ‘don’t know’ were excluded from this analysis. No statistically significant association was found between a perceived high workload and whether the nursing process was central in the records (Wilcoxon rank-sum test: p  = 0.542), see Table  6 .

Association between perceived workload and whether the nursing process is central in electronic health records

Like the survey respondents, virtually all community nurses in the focus groups were positive about how the nursing process was integrated in the electronic health records they worked with.

“I think we have a very nice system that functions well. [...] I also get sufficient support from this system in my task as a community nurse monitoring the nursing process.” (Focus group 4, online).

Hence, this feature of the electronic health records was not associated with the workload of the community nurses.

The present study revealed that the majority of community nurses participating in the survey and focus groups perceived documentation as a cause of their high workload. These findings are in line with previous research that indicated that documentation can be burdensome to nurses [ 9 , 10 ]. Although community nurses spent twice as much time on clinical documentation compared to organizational documentation, the survey showed that community nurses were just as likely to perceive a high workload due to clinical documentation as to organizational documentation. In the focus groups, nurses indicated that organizational documentation in particular was a cause of their high workload. They were more positive about clinical documentation since they experienced that as a meaningful and integral part of the care for individual patients. This view is in line with professional guidelines that describe clinical nursing documentation as an integral part of nursing care for individuals [ 24 – 26 ].

Nevertheless, the survey in particular showed that community nurses often did perceive a high workload due to clinical documentation as well. In the focus groups participants had more opportunity to reflect on and to discuss the value of clinical documentation versus organizational documentation, and this may have resulted in more positive views on clinical documentation.

Still, it is rather surprising that particularly in the survey clinical documentation was associated with a high workload by so many community nurses. Previous research by Fraczkowski, Matson [ 45 ];Michel, Waelli [ 20 ];Moy, Schwartz [ 46 ];Vishwanath, Singh [ 47 ];Wisner, Lyndon [ 30 ] indicated that electronic clinical documentation is associated with documentation burden by health care professionals. It seems important that all nurses are made aware that clinical nursing documentation is important for providing good patient care. This awareness might reduce nurses’ perceived workload associated with documentation activities. On top of that, further integrating clinical documentation in individual patient care and improvements in the electronic health records are needed [ 45 , 48 ].

For optimal integration of clinical documentation in patient care, it is important that the electronic health records reflect the phases of the nursing process [ 6 , 31 ]. However, our study showed no association between the extent of nurses’ perceived workload and whether the electronic health records was following the nursing process. A possible explanation is that most community nurses (78.7%) already found that the nursing process was central in their electronic health records.

A key recommendation for care organizations and software developers is to improve electronic health records in terms of their user-friendliness [ 4 , 31 ]. Other recent studies also linked the limited usability or user-friendliness of electronic health records to nurses’ perceived time pressure [ 29 , 49 ]. The community nurses participating in the focus groups also recommended improvements in the user-friendliness of electronic health records and stated that that would reduce their workload. Examples would be removing mandatory sections in electronic health records and working on better communication between systems within and across care organizations and healthcare professionals.

Furthermore, focus-group participants recommended linking the content of the different electronic systems for clinical and organizational documentation so that relevant information only has to be documented once. Other research also indicated that duplication in documentation is a problem for nurses and is accompanied with negative views on documentation [ 11 ]. Moreover, studies showed a poor match between different electronic health records both in the digital formats that are used and in the professional vocabulary and standard terminologies used [ 50 , 51 ]. Improvements in electronic health records, linkages between different electronic systems and more uniformity in language could facilitate information sharing with other healthcare professionals and interdisciplinary care [ 48 , 52 ].

Another finding in our study was that although clinical documentation was also associated with a high workload, time spent on organizational documentation was considered even more problematic. Unlike clinical documentation, organizational documentation was often seen as pointless. Spending a great deal of time on organizational documentation gave feelings of frustration and a high perceived workload. Our study did not differentiate between different kinds of organizational documentation in terms of the aims of the documentation, e.g. financial accountability for insurers, quality indicators for the Health Inspectorate, safety and quality management for the nurse’s own care organization, etcetera. The association between the specific aims of organizational documentation and nurses’ perceived workload could be a subject for future research. In addition, further research should focus on the integration of clinical documentation in patient care and the user-friendliness of electronic health records.

Limitations and strengths

A limitation of this mixed-methods study is that the survey participants and focus-group participants differed in age: the focus-group participants were on average younger than the survey participants. We looked at the survey data for a possible correlation between age and perceived workload but did not find statistically significant differences.

A second limitation is that we used a self-developed survey questionnaire. However, we based the questionnaire on relevant literature, including the ‘Nursing Process-Clinical Decision Support Systems Standard’ [ 12 , 31 ]. Furthermore, we tested the questionnaire in a pilot study for comprehensibility among nursing staff. Hence, we consider the questionnaire to be a comprehensive and content valid instrument to assess nurses’ experiences with documentation in relation to their perceived workload.

A strength of this study was the use of mixed-methods research, which provided a deeper understanding of community nurses’ documentation activities in relation with their perceived workload. The focus groups that were organized after the survey gave additional and more in-depth insights, particularly regarding nurses’ views on the two types of documentation and the user-friendliness of electronic health records.

The majority of community nurses regularly perceived a high workload due to documentation activities. Although nurses spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these types of documentation was comparable. The extent to which nurses perceived a high workload was related to time spent on organizational documentation in particular. Nurses believed spending substantial time on clinical documentation was worthwhile, while spending a great deal of time on organizational documentation led to frustration. Therefore, a reduction in the time needed specifically for organizational documentation is important.

Particularly in the focus groups, nurses highlighted the importance of user-friendly electronic health records in relation to perceived workload. Improving the user-friendliness of electronic health records, improving the intercommunicability of different electronic systems, and further integrating clinical documentation in individual patient care are also recommended as measures to reduce the workload that community nurses perceive from documentation activities.

Acknowledgements

We would like to thank the participants of the Dutch Nursing Staff Panel and all other community nurses who participated in this study. Furthermore, we thank Clare Wilkinson for the language editing.

Authors’ contributions

KdG, AdV, AF and WP developed the study concept and design. KdG, AdV and AM carried out the data collection. All authors (KdG, AdV, AM, AF, WP) contributed to the analysis and interpretation of the data. All authors contributed to the drafting and revision of the article. All authors read and approved the final manuscript.

The Dutch Nursing Staff Panel is financed by the Ministry of Health, Welfare and Sports. The funder had no role in conducting this research. No specific funding was received for the focus groups.

Availability of data and materials

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The authors declare that they have no competing interests.

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Volume 18 Supplement 1

Selected articles from the 6th Biennial International Nursing Conference

• Open access
• Published: 16 August 2019

Nursing care activities based on documentation

• Mira Asmirajanti 1 ,
• Achir Yani S. Hamid 2 &
• Rr. Tutik Sri Hariyati 2  

BMC Nursing volume  18 , Article number:  32 ( 2019 ) Cite this article

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Nurses engage in various activities from the time of a patient’s admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed.

A quantitative design with a retrospective approach was used, in which 240 medical records from Dr. Kariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records were randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it to be considered. The results were analyzed to compare the standard of care.

It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities, according the standard of nursing activities, included the assessment of the functional status of decubitus risk (20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patients’ home needs (41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and resume activities nursing (0.8%).

Conclusions

Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing activity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality of nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.

Nurses are involved in many activities in a hospital from patient admission through discharge. They provide continuous 24-h patient care, which is divided into several shifts [ 1 ]. Patient care includes performing assessments, stating nursing diagnoses, developing intervention plans, implementing care, and making evaluations to modify or terminate care [ 2 ]. Examples of nursing interventions include discharge planning and education, the provision of emotional support, self-hygiene and oral care, monitoring fluid intake and output, ambulation, the provision of meals, and surveillance of a patient’s general condition [ 3 ]. The delivery of nursing care should involve the patient. A nurse respectfully communicates, coordinates, and integrates nursing care, provides education and information, and considers the comprehensive and continuous physical and emotional comfort of the patient [ 4 ]. In addition, a nurse employs an appropriate strategy to establish a good rapport with a patient and is able to understand a patient’s condition in such a way that they can motivate him or her to actively participate in every nursing activity [ 5 ].

Each nursing activity should consider patient safety. Nurses are responsible for preventing patients from falling and from developing pressure ulcers, urinary tract infections, and nosocomial infections [ 6 ]. They provide education and information regarding the procedures involved in nursing interventions beforehand and involve patients for their own safety; effective communication is the key to patient safety [ 7 ].

Nursing activity that has been completed or that will take place should be properly documented. Accurate documentation and reports play a pivotal role in health services [ 8 ]. This documentation is necessary to identify nursing interventions that have been provided to patients and to show patient progress during hospitalization [ 9 ]. It is also an indicator of nurse performance and the nursing service quality in a hospital. Documentation provides details of patient condition, nursing interventions that have been provided, and patient response to the intervention(s) [ 10 ].

Nursing documentation also serves as an effective tool of inter-professional communication between nurses and other health professionals for delivering ongoing nursing care, evaluating patient progress and outcomes, and providing constant patient protection [ 11 ]. High-quality nursing documentation may improve the effectiveness of communication between health professionals in first- and higher-level healthcare facilities [ 12 ].

The documentation should be saved for an appropriate length of time and should be concise and clear; complete, accurate, and up-to-date documentation will protect a nurse in a court of law [ 13 ]. Correct documentation may encourage a nurse to establish continuity between the diagnosis, intervention, progress, and evaluation of the outcome [ 14 ]. A previous study revealed that 54.7% of nursing documents were of poor quality and 71.6% were incomplete [ 15 ]. Supervision by the head nurse is required for complete, concise, and accurate documentation of nursing care [ 16 ]. The information above provides a platform for managers and nurses to better understand the delivery of nursing care.

A quantitative, cross-sectional, and retrospective study used the medical records of discharged patients. The medical records concerned patients who had been hospitalized for more than 3 days at the medical surgical ward.

Setting and sample

The study was conducted in DK Hospital of Semarang from October until December 2016. Data were obtained from July to September 2016 from 240 medical records of patients with the 10 most common medical surgical diseases. The 240 medical records were randomly selected by simple random methods based on even and odd numbers. Ethical clearance procedures were followed. Medical records data were maintained confidentially, were used only for research purposes, and were not disseminated for other purposes.

Data collection

The authors recorded all nursing activities performed by nurses from the time of a patient’s admission until his or her discharge via an observation form that had been developed by referring to patient progress notes. This observation form consists of nursing activities and had been tested for validity and reliability to achieve optimal data. The validity and reliability results were r Alpha > 0.90 and coefficient kappa > 0.80.

Data analysis

The collected data were assigned codes, inputted into a computer, and cleared of unnecessary information. The data were checked during entry and compilation before analysis. After checking the data for completeness, missing values, and coding questionnaires, data were entered into the computer and analyzed. Univariate analysis was used to identify the frequency and percentage of nursing activities performed. The results were analyzed to compare the standard of care with the hospital accreditation standard and needed to be at least 80% of the values for a certain criteria for it to be considered.

A total of 240 medical records for patients who had been hospitalized for more than 3 days in the medical surgical ward were obtained and analyzed. Data were obtained from the documentation completed by nurses while providing nursing care for each patient. These activities involved patient identification, assessment, nursing diagnosis formulation, discharge planning, education, intervention, monitoring and evaluation, mobilization/rehabilitation, and nursing outcomes. The results are presented in Table  1 below.

The results show that the nurses performance on some nursing activities were below standard (80%). Some nursing activities which needed to be optimized including the assessment of functional status, risk of a pressure ulcer (20.8%), assessment of biological aspect (0.4%), formulation of a nursing diagnosis (20.8%), collaboration in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of activities of daily living (ADL) (37.5%), mobilization/rehabilitation (37.5%), nursing outcome (46.7%), identification of patients’ home (41.3%), quality of life (66.3%), and nursing activities resumé (0.8%).

The results also indicated that nursing activities were not implemented in compliance with the nursing process; for example, some nurses had not properly performed a biological assessment before proceeding to formulate their diagnosis and perform an intervention. Although the interventions were properly executed, the mobilization and monitoring activities could be improved. Nurses rarely formulated a nursing diagnosis before the expected outcome; however, these two activities should be performed in order, since it may affect the planned nursing intervention. The nurses did not properly identify the patients’ home needs in discharge planning, nor did they create an optimal nursing activities resumé.

The results revealed that nursing activities to solve problems and meet patient needs in the provision of nursing care were not systematically performed and critical thinking was not applied during the nursing process. A previous study asserted that the nursing process incorporates the assessment, nursing diagnosis, planning, implementation, evaluation, and documentation [ 16 ]. The phases in the nursing process are interconnected and become a continuous cycle. Therefore, steps in this process are interrelated, interactive, and cannot stand alone [ 17 ].

It was also shown that some nurses did not perform a biological assessment, yet they proceeded to formulate nursing diagnoses and perform interventions. A nursing diagnosis, however, should be based on the assessment result and used as reference in determining the intervention [ 18 ]. Nurses should consider using a nursing process that complies with the input, process, and output in formulating an intervention, since it may affect the quality of care and patient safety in general [ 19 ]. Patient safety is a fundamental concern for all nurses and health professionals, from the patient’s admission to the hospital until discharge; therefore, it is required that every nursing process is implemented according to the standards applied and in a sustainable manner. If these standards are not observed, then the nurses and other health professionals would not meet patient needs and may even compromise patient safety.

It was shown that nursing activities in identifying the patients’ home needs and quality of life during discharge planning were not properly implemented. Discharge planning is a crucial nursing activity that facilitates a patient’s readiness regarding his or her discharge from the hospital; it allows a patient to be safely transferred from the hospital to their own home. Lack of nursing support in this activity has previously resulted in an increased number of patient readmissions [ 20 ]. Although discharge planning also involves other healthcare professionals, the nurse has the longest amount of time to interact with the patient. The nurse should understand the patient’s condition, recognize their ability to accept it, and improve the readiness of the patient and their family for continuing care at home.

The collaboration intervention of drug administration was not fully implemented. Nurses should provide education regarding the function, composition, and side effects of a drug and adverse reactions that may occur with uncontrolled use. Therefore, a nurse should ensure that a patient has been properly informed of the drug prescribed by a physician. A previous study revealed that collaboration in drug administration in provision of nursing care may improve patient satisfaction and reduce their stress and anxiety [ 5 ].

The findings revealed that nursing activities in vital signs and ADL monitoring were not correctly implemented. Monitoring is a critical nursing activity and identifies a patient’s condition and ability to meet their daily needs so that a nurse may devise an appropriate intervention. A previous study revealed that nurses played a pivotal role in helping patients to recuperate by performing an assessment, monitoring, intervention, evaluation, and provision of support [ 21 ], immediately recognizing a change in a patient’s condition, health promotion, preventing morbidity, improving patient satisfaction, and quality of care.

In the present study, nursing activities in patient mobilization/rehabilitation were not properly executed. Patient mobilization/rehabilitation is an activity that must be implemented immediately after a patient’s hemodynamic parameters are stabilized in order to improve their physical condition. A previous study stated that nurses should pay heed and motivate patients in rehabilitation to ensure effective and cost-effective care [ 22 ].

The present findings also showed that nursing activities in deciding the patient outcome were not optimal. The determination of outcome serves to evaluate how much progress has been made by a patient following the delivery of nursing care. Indeed, one study claimed that the determination of outcome reflected the unique contribution of nursing care toward patient safety [ 23 ].

The present findings of improper nursing activities may have resulted from numerous factors, such as having to perform a large number of non-nursing duties, manual documentation, a lack of standards in documenting patient progress notes, and the exclusion of nursing care in calculating remuneration.

All nursing activities should be properly documented as authentic information and used to evaluate nursing care and professional competency. Nursing documentation is an essential component of professional practice to improve the quality of nursing care and should be accurate and complete [ 24 , 25 ]. Complete documentation encourages nurses to work effectively and appropriately [ 14 ].

Some nursing activities have been done properly, but they were not continuously in compliance with the nursing process. Nursing care was not systematically performed and critical thinking was not applied during the nursing process. Many nurses did not do a biological assessment, yet they proceeded to formulate nursing diagnoses and perform interventions. Nursing activities in identifying patients’ home needs and quality of life during discharge planning, collaboration intervention of drug administration, vital signs and ADL monitoring, patient mobilization/rehabilitation. and deciding the patient outcome were not properly implemented.

The nursing process should be properly implemented in order to improve patient and nurse satisfaction, quality of care, patient safety, and cost-effectiveness, as well as to reduce the average length of stay. A nurse who has completed nursing activities is required to document the care provided, according to the standard applied. Nursing activities and documentation may be more likely to be optimal if they are regularly directed, controlled, and evaluated by the nurse manager. A nurse and patient satisfaction survey should also be periodically conducted to evaluate the quality of nursing activities in the delivery of nursing care for patients.

Abbreviations

Activities of daily living

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Acknowledgements

The authors would like to thank the Faculty of Nursing, Universitas Indonesia for financial support. Their grateful thanks also go to the informants who participated in the study and openly shared their thoughts and experiences.

The publication cost of this article was funded by PITTA Universitas Indonesia grant, under grant no.365/UN2.R3.1/HKP.05.00/2017.

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The data and materials used for analysis and make conclusion are available from the corresponding author on reasonable request.

About this supplement

This article has been published as part of BMC Nursing Volume 18 Supplement 1, 2019: Selected articles from the 6th Biennial International Nursing Conference. The full contents of the supplement are available online at https://bmcnurs.biomedcentral.com/articles/supplements/volume-18-supplement-1 .

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Asmirajanti, M., Hamid, A.Y.S. & Hariyati, R.T.S. Nursing care activities based on documentation. BMC Nurs 18 (Suppl 1), 32 (2019). https://doi.org/10.1186/s12912-019-0352-0

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Examples & functions of nursing documentation.

“If You Didn’t Write It Down, You Didn’t Do It”

This old nursing adage, applicable to all nursing documentation examples, has to be one of the oldest and most frequently used teaching tools in nursing education, yet it remains as valid today as it was a century ago. According to an article by Nikki Campos, “The Legalities of Nursing Documentation,” published on Lippincott’s online NursingCenter.com , “the objective of any state’s nursing practice, act as it pertains to documentation is the same across the country: to provide a clear and accurate picture of the patient while under the care of the healthcare team.” Communication to other healthcare providers is the first function of nursing documentation, always with an eye toward the goal of meeting and documenting standards in patient care.

Examples of Nursing Documentation

Even as nursing documentation transitions from written records to Electronic Health Records (EHRs), the types of routine nursing documentation remain the same. The most common types of nursing documentation include the following:

Nursing Progress Notes

Nursing progress notes are one of the most frequent and time consuming of nursing documentation tasks. In addition to the historical narrative notes, several other systems have been devised over the years to save time, improve documentation and standardized nursing notes. Types of progress note documentation systems include:

Narrative Nursing Notes

• Traditional
• Time-consuming
• Inconsistent quality demonstrated
• Used in typical “source records” hospital charts with information organized by information sources

Problem-Oriented Nursing Notes

• Also referred to as Problem-Oriented Medical Records or “POMR”
• Data is ideally organized by diagnosis
• All members of the healthcare team utilize the progress note section
• (S) Patient’s subjective complaint
• (O) Objective findings
• (A) Assessment findings
• (P) Nursing or medical plan
• (I) Intervention
• (E) Evaluation of effectiveness
• PIE Charting
• (P) The problem as identified
• (I) A planned intervention
• (E) An evaluation of the efficacy of the intervention
• (D) Objective data documenting problem
• (A) Action or intervention planned
• (R) Patient response to intervention conducted
• DAR Focus Charting

Charting By Exception Nursing Notes

• Used primarily in long-term care facilities
• Decreases burden of frequent documentation of a primarily unchanging condition
• Saves time and decreases the size of medical record
• Assumes all standards are met unless otherwise noted
• Exceptions require documentation

Nursing Admission Assessment

Nursing admission assessments are multipage forms that document a patient’s current condition, previous medical history, allergies, prescription drugs and primary complaint at the time of his or her admission to the hospital. The information is collected through an interview conducted with the patient and/or family and via a careful physical examination by the admitting nurse. The information and data garnered during a nursing admission assessment forms the basis of the nursing care plan. Some facilities have different admission assessments utilized for the different types of care provided. For instance, a patient may require an Emergency Department (ED) Nursing Admission Assessment followed by an Intensive Care Unit (ICU) Admission Assessment completed upon transfer. When the patient improves enough to be transferred to the general medical population, he or she will often have another nursing admission assessment completed to reflect the new goals for the patient’s improved condition.

Nursing Care Plans

Nursing care plans are the organized means by which patient problems (nursing diagnoses) are identified, and nursing interventions prescribed to address the patient’s physical, mental, social, psychological or educational needs. Characteristics of these documents include:

• Standardized plans of care based upon disease or nursing diagnosis
• Modification of the care plans based upon the patient’s individual needs
• Promotes improved and standardized means of patient care
• Ensures treatment based on the same minimum level of knowledge among all healthcare providers

Graphic Sheets

Graphic sheets refer to charts and graph that aid in documenting objective physical measurements required during patient care. These include:

• Allows graphing of patient pulse, blood pressure, temperature and respiratory rate on a single multidimensional graph
• Provides an area for recording patient weight
• Intake/Output Record (I & O)
• Allows staff to record patient fluid intake by mouth or intravenously to be totaled at the end of each shift and each day
• Allows staff to record patient fluid output by urinary catheter, nasogastric suction or urination into measured containers to be totaled at the end of each shift and each day
• The resulting sum allows staff to document fluid retention or hypovolemia

Medication Administration Records (MARs)

Whether hand-written, partially computerized or totally computerized, medical administration records (MARs) document what medications are prescribed to each patient, the dosage, the administration route, and the administration schedule. Each nurse “initials” or indicates administration of each medication as provided to his or her assigned patients. MARs are reviewed prior to each nursing shift to ensure that any medication changes have been properly recorded.

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