The accuracy of patient records in Swedish nursing homes: congruence of record content and nurses' and patients' descriptions

Data from patient records will increasingly be used for care planning, qual ity assessment, research, health planning and allocation of resources. Know ledge about the accuracy of such secondary data, however, is limited and on ly a few studies have been conducted on the accuracy of nursing recording. The aim of this study was to analyse the concordance between the nursing do cumentation in nursing homes and descriptions of some specific problems of nurses and patients. Comparisons were made between wards where nurses had r eceived training in structured recording based do the nursing process (stud y group) and wards where no intervention had taken place (reference group). Data were collected from the patient records of randomly selected nursing home residents (n = 85). The methods used were audits of patient records an d structured interviews with residents and nurses. The study revealed consi derable deficiencies in the accuracy of the patient records when the record s were compared with the reports from nurses and residents. The overall agr eement between the interview data from nurses and from the patient records was low. Concordance was better in the study group as compared with the ref erence group in which the recorded data were structured only following chro nological order. The study unequivocally demonstrates that there are major limitations in using records as a data source for the evaluation, planning and development of care.