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Documentation and the transfer of clinical information in two aged care settings
Dianne Pelletier1, Christine Duffield, Judith Donoghue
1Centre for Health Services Management, University of Technology, Sydney, Australia. dianne.pelletier@uts.edu.au
Background:
Increasingly, documentation, both formal and informal, is being undertaken by nurses using a range of modalities. In Australia there is a sense that the demand for this in the aged care sector is increasing in line with requirements of funding agencies. However, the scope of this activity and its impact on nursing workload in aged care facilities has not been rigorously investigated. Funding of aged care facilities in the public hospital system in Australia is dependent on documentation of care.
Objective:
The purpose of this study was to determine the frequency and time of day that documentation and transfer of clinical information activities occurred for nurses of all skill levels in two aged care facilities in New South Wales, Australia.
Design:
Work sampling of direct care, indirect care, unit-related activities and personal time.
Setting:
Two hospitals with aged care facilities near Sydney, Australia.
Subjects:
One hundred and six nurses.
Results:
16,395 observations of nursing activities were recorded. The transfer of clinical information between health care professionals comprises a large part of the nurse's working day. It comprised between 37 and 38% in this study, but the time of day in which it took place differed between the two hospitals.
Conclusion:
Documentation needs to be seen as an integral part of care by managers and clinicians. Both would wish to ensure that it is undertaken in the most efficient and effective manner to allow the necessary time for direct care. More detailed understanding may allow clinical unit managers to re-structure the workday in terms of documentation to achieve greater efficiencies or effective use of nursing time.
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