A Cross-Sectional Study of How Cancer Nurses Document the Nursing Processes Using Digital Health Record (DHR).

Area of Science:

• Nursing Informatics
• Health Information Management
• Oncology Nursing

Background:

• Digital Health Records (DHR) are increasingly used in cancer care settings.
• Effective nursing documentation is crucial for quality patient care and continuity.
• Understanding current documentation practices within DHR is essential.

Purpose of the Study:

• To explore how nurses document the nursing process within a cancer care setting using DHR.
• To assess the completeness and quality of nursing documentation in DHR.

Main Methods:

• A cross-sectional study design was employed.
• Twenty clinical care records from an Australian medical oncology inpatient ward were audited.
• The D-Catch instrument was used to evaluate the five elements of the nursing process in DHR.

Main Results:

• High scores were observed for the completeness and quality of nursing documentation across most aspects of the nursing process.
• Documentation of patients' holistic care needs was notably low or absent.
• The D-Catch tool proved useful for assessing nursing process documentation.

Conclusions:

• While overall nursing documentation quality in DHR is positive, gaps exist in capturing holistic care needs.
• Further investigation is needed to optimize the usability of tools like D-Catch within digital environments.
• Addressing documentation deficits in holistic care is critical for comprehensive cancer patient management.