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Nursing diagnosis in home care: audit tool development
1Department of Nursing, School of Professional Studies, Southern Connecticut State University, New Haven 06515.
Journal of Community Health Nursing
|January 1, 1994
Summary
This study examined nursing diagnosis documentation in home care. Findings indicate that certain nursing diagnoses, when documented together, correlate with an increased number of client visits.
Area of Science:
- Nursing
- Healthcare Management
- Home Care Services
Background:
- Limited research exists on the value of nursing diagnoses in home care settings.
- Increasing client acuity levels may impact diagnostic selection in home care.
- Nursing diagnoses are crucial for effective patient care planning and documentation.
Purpose of the Study:
- To investigate the relationship between nursing diagnosis documentation and client/visit variables in home care.
- To assess the impact of increased client acuity on the selection of nursing diagnoses.
- To evaluate the utility of a newly developed instrument, the Home Care Audit Tool.
Main Methods:
- Retrospective chart audit of 199 closed home care records.
- Utilized a newly developed instrument: the Home Care Audit Tool.
- Analyzed client demographics and nursing diagnosis documentation.
Main Results:
- The average number of nursing diagnoses per case was 1.75.
- A positive correlation was found between specific nursing diagnoses documented together and an increased number of recorded visits.
- The client population had a mean age of 76 years, with 64% females.
Conclusions:
- Nursing diagnosis documentation in home care is linked to client and visit patterns.
- The presence of certain combined nursing diagnoses may indicate a need for more intensive home care services.
- Further research is warranted to fully understand the impact of nursing diagnoses on home care resource allocation.