The nursing record as a research tool to identify nursing interventions

Area of Science:

• Nursing Research
• Healthcare Informatics
• Patient Care Evaluation

Background:

• Nursing documentation is crucial for continuity of care and quality assessment.
• Retrospective review of nursing records is a common method for data collection.
• Accuracy of documented nursing interventions requires validation against actual practice.

Purpose of the Study:

• To evaluate the feasibility of using retrospective case note abstraction to identify nursing interventions.
• To assess the accuracy of nursing records in reflecting actual patient care for myocardial infarction and fractured femur patients.
• To compare documented care with nurses' reported practices in specific care areas.

Main Methods:

• Retrospective case note abstraction using a data collection tool.
• Interviews with nurses who cared for patients and senior ward nurses.
• Comparison of documented interventions with self-reported nursing practices.

Main Results:

• Nursing records provided data on interventions for myocardial infarction (pain, mobility, anxiety, education) and fractured femur (pressure areas, pain, nutrition, mobility, rehabilitation, information).
• Discrepancies were observed between documented care and nurses' reported practices.
• Methodological and logistical challenges were identified in the data abstraction process.

Conclusions:

• Retrospective case note abstraction is a feasible method for identifying nursing interventions but requires careful validation.
• Accuracy of nursing records may be variable, necessitating methods to ensure comprehensive and truthful documentation.
• Further research is needed to refine methods for evaluating the accuracy of nursing documentation and its reflection of patient care quality.