Review of nursing documentation in nursing home wards - changes after intervention for individualized care

Using standardized assessment instruments may help staff identify needs, pr oblems and resources which could be a basis for nursing care, and facilitat e and improve the quality of documentation. The Resident Assessment Instrum ent/Minimum Data Set (RAI/MDS) especially developed for the care of elderly people, was used as a basis for individualized and documented nursing care , This study was carried out to compare nursing documentation in three nurs ing home wards in Sweden, before and after a one-year period of supervised intervention. The review of documentation focused on structure and content in both nursing care plans and daily notes. The greatest change seen after intervention was the writing of care plans for the individual patients. Dai ly notes increased both in total and within parts of the nursing process us ed, but reflected mostly temporary situations. Even though the documentatio n of nursing care increased the most, it was the theme medical treatment wh ich was the most extensive overall. A difference was seen between computer- triggered Resident Assessment Protocol (RAP) items, obtained from the RAI/M DS assessments, and items in the nursing care plans; the former could be re garded as a means of quality assurance and of making staff aware of the nee d for further discussions. The RAI/MDS instrument seems to be a useful tool for the dynamic process in nursing care delivered and as a basis for docum entation. The documentation should communicate a patient's situation and pr ogress, and if staff are to be able to use it in their everyday nursing car e activity, it must be well-structured and freely available. The importance of continuing education and supervision in nursing documentation for devel opment of a reliable source of information was confirmed by the present stu dy.