Exploration of note writing by mental health nurses using a video scenario

We aimed to explore the content and language of nursing documentation and gain insight into the internal processes of nurses while notetaking.

Documentation is a core competency of mental health nursing, has clinical and ethical importance and is the integral to the efficient and effective care provided to patients. However, issues related to the content and quality of nursing notes continues to be a concern and there remains gaps in our understanding about the internal processes that nurses engage in when writing notes.

We used a mixed method design that included a content analysis with note review and interviews.

After watching a video, psychiatric nurses (n = 27) wrote a note and then were interviewed about their note taking process. We used the COREQ guidelines for reporting our data.

Participants relied on four main themes when determining what to include in their notes-what happened and what the patient said or did, plus anything different than baseline, and safety concerns. Analyses revealed the presence of bias in the notetaking and participants were not familiar with effective strategies to mitigate these during the documentation process. Lastly, we found that notes are typically consistent in using some of the SOAPE format with notes focused on direct observations and the use of 'facts', while assessment and construction of treatment plans are used to a lesser extent.

Our results provide insight into the decision-making process of nursing staff regarding their documentation practices: overall they appear unaware of the importance of their notes, and believe that capturing the facts about their patients is important, while devaluing their own input and interpretations.

Our results provide evidence that mental health nurses may need additional training regarding documentation, more specifically about what to include, word choice and bias.