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Role of Communication in the Nursing Process III: Evaluation and Documentation

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Guidelines for Nursing Documentation II

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Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
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Related Experiment Video

Updated: May 19, 2026

Using Learning Outcome Measures to assess Doctoral Nursing Education

Using Learning Outcome Measures to assess Doctoral Nursing Education

Published on: June 21, 2010

Evaluating an intensive ward-based writing coach programme to improve nursing documentation: lessons learned.

D Jefferies¹, M Johnson, D Nicholls

¹School of Nursing and Midwifery, Centre for Applied Nursing Research (Joint Facility of SSWAHS & the University of Western Sydney), College of Health & Science, University of Western Sydney, Sydney, NSW, Australia. d.jefferies@uws.edu.au

International Nursing Review

|August 18, 2012

Summary

This summary is machine-generated.

A ward-based writing coach program improved nursing documentation quality. Regular audits also prompted nurses to enhance patient information, supporting better care planning.

Related Experiment Videos

Last Updated: May 19, 2026

Using Learning Outcome Measures to assess Doctoral Nursing Education

Using Learning Outcome Measures to assess Doctoral Nursing Education

Published on: June 21, 2010

Area of Science:

Nursing
Healthcare Quality Improvement
Clinical Documentation

Background:

Incomplete patient information in nursing notes compromises care planning reliability.
Previous strategies to enhance nursing documentation quality have yielded limited success.
A novel educational intervention involving one-to-one coaching within the clinical setting was evaluated.

Purpose of the Study:

To develop and assess a ward-based writing coach program aimed at elevating the quality of patient information within nursing documentation.
To investigate the effectiveness of a structured coaching intervention in improving the comprehensiveness and accuracy of nursing notes.

Main Methods:

A concurrent mixed-methods approach was employed, integrating a pre-post intervention and control design for quantitative analysis.
Qualitative data were gathered through a focus group comprising eight nurses.
Healthcare records of 175 patients (87 intervention, 88 control) were audited using the Nursing and Midwifery Content Audit Tool.

Main Results:

No statistically significant differences in documentation quality criteria were observed between intervention and control wards.
Most quality documentation criteria were met in over 75% of patient records across both groups.
Qualitative themes highlighted the program's impact on nurses and patients, documentation challenges, medicolegal considerations, and coach attributes.

Conclusions:

Writing coaching offers a supportive strategy for enhancing nursing documentation.
Regular auditing serves as a catalyst for nurses to improve the quality of their documentation.
Further research with larger sample sizes is recommended to validate these findings.