Documentation of client encounters by public health nurses at a county health department

Documentation of high-risk infant (HRI) encounters in the nursing flowsheet by public health nurses (PHNs) at a county health department is evaluated for its effectiveness. A convenience sample of 31 client records was used. The effectiveness in documentation was evaluated in terms of PHNs' adherence to guidelines provided for the use of the particular nursing flowsheet. The frequency of correct documentation was determined for assessment, intervention, and outcome measures. Within the category of assessment, a high rate of correct documentation was found for the items, elimination, and bonding status. A moderate rate of correct documentation was noted for items pertaining to physical assessment, health-care system used, child abuse and neglect potential in the home, and safety. Documentation of anticipatory guidance or intervention provided was minimal throughout the flowsheet. The outcome measures, expressed as goal statements, were by comparison, more often documented correctly.