Visibility of the caregiver role in nursing documentation for hospitalized older adults: A cross-sectional study

Family caregivers play a vital role in supporting dependent older adults, particularly during hospital-to-home transitions. Yet their contribution often remains insufficiently documented in nursing records, which may limit the visibility of caregiver-related information across care settings.

To examine the visibility of the nursing focus "Caregiver Role" in electronic nursing records of hospitalized older adults and its incorporation into discharge documentation.

A retrospective cross-sectional study was conducted using electronic nursing records of 577 patients aged ≥65 years with documented self-care dependence, admitted to an internal medicine department in a European country (January-March 2023). Data were retrieved from the national electronic health record (SClínico®), which uses the International Classification for Nursing Practice (ICNP) to structure nursing diagnoses and interventions. Descriptive statistics were applied.

Although caregivers were routinely identified at admission, only 76 patients (13.2%) had at least one documented caregiver-related nursing focus. Among these, 124 caregiver-related diagnosis entries were recorded, most frequently "Committed caregiver role." Interventions were primarily classified under generic categories (e.g., assess, guide). Fewer than 10% of discharge documentation included caregiver-related content.

These findings indicate a discrepancy between the identification of family caregivers and their formal integration into nursing care plans and discharge documentation. Improving the systematic documentation of caregiver-related information may enhance the continuity and visibility of caregiver involvement across care transitions.