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  Copyright © eContent Management Pty Ltd. Contemporary Nurse  (2012) 41 (2): 160–168. 160 C   N  C   N  Volume 41, Issue 2, June 2012 Nursing documentation: Frameworks and barriers W ENDY  B LAIR   AND B ARBARA S MITH NZNO, HWNZ Post Graduate Coordinators Group, MidCentral Health Nurse Governance Council,Palmerston North, New Zealand The quality of nursing documentation is an important issue for nurses both nationally and internationally. Nursing docu-mentation should, but often does not show the rational and critical thinking behind clinical decisions and interventions,while providing written evidence of the progress of the patient. A number of frameworks are currently available to assist with nursing documentation including narrative charting, problem orientated approaches, clinical pathways, and focus notes. However many nurses still experience barriers to maintaining accurate and legally prudent documentation. A review of nursing documentation of patient care and progress towards achieving outcome goals in our organisationidentified a lack of clear and easy to follow information about the patient’s progress. In order to address with this issue a  project group was established to look at different frameworks for nursing documentation. The aim of the project was toidentify and implement a documentation framework that would encourage critical thinking and provide evidence of the rationale for nursing actions utilising a problem based approach in order to provide accurate evidence of patient progress.This paper provides a synopsis of available literature related to the frameworks mentioned above, highlights barriers tosafe, timely and accurate documentation for nurses, and concludes with an explanation of the framework chosen as a result of this review. Keywords: nursing documentation; nursing reports; literature review; progress notes T he quality of nursing documentation is animportant issue for nurses both nationally andinternationally. It is clear from many cases on theNew Zealand Health and Disability Commissioner Website (Health and Disability Commissioner,2009) that issues related to poor nursing docu-mentation need to be urgently addressed. Differentnursing documentation methods such as SOAPIEare used to provide frameworks that guide nursing documentation. However these methods do notnecessarily meet the documentation needs of busy clinical areas in the current health environmentbecause they focus on single problem entries andpatients are often complex with multiple problems.Nursing documentation in our organisationhas lacked a clear rationale for clinical decisionsand evidence of critical thinking. In order to deal with this issue a project group was established tolook at different methods of nursing documenta-tion. The aim of this project was to identify a method that would encourage critical thinking by using a problem based approach. This articleprovides a summary of the literature reviewed atthe commencement of this project and a sum-mary of the framework chosen as a result of thisreview.The review of literature sought to identify cur-rent methods of nursing documentation in orderto identify any that could be used to improvethe quality of nursing progress notes. A litera-ture search was performed using CINAHL andMEDLINE. Key words used included the follow-ing; documentation, progress notes, and nursing reports. The review focused on documentationmethods, problem orientated documentation,barriers to documentation, risk management, andlegal implications. Literature published between1998 and 2011 was reviewed. Some seminal piecesof literature have been included from 1974 to 1997as these provide relevant background informa-tion. Much of the more recent literature availableis in the form of systematic reviews with a focuson electronic documentation (Kelly, Brandon,& Dicherty, 2011), audit instruments (Wang,Hailey, & Yu, 2011), and accuracy of documenta-tion (Paans, Nieweg, Van der Schans, & Sermeus,2011) which have not been discussed in this paper.Much of the available literature accessed wasrelated to nursing documentation within acutecare settings and srcinated from Europe (Darmeret al., 2006; Ehrenberg & Birgersson, 2003;Ehrenberg, Ehnfors, & Thorell-Ekstrand, 1996;  Nursing documentation 161 C   N  C   N  C   N  C   N  © eContent Management Pty Ltd Volume 41, Issue 2, June 2012 continuity of care and reduction of risk has alsobeen raised as an issue in other health related disci-plines, with social work and physical therapy expe-riencing similar challenges to nursing (Delaune &Bemis-Dougherty, 2007; Reamer, 2005). Anecdotal evidence suggests that the stan-dard of nursing documentation is suffering as a result of the time pressure that nurses in many clinical environments are experiencing. Currentissues include the lack of timely entries, lack of comprehensive and accurate information, and a lack of accurate assessment information and fol-low through care planning. Accurate documenta-tion facilitates communication, promotes nursing care, helps to meet professional and legal require-ments, aids quality improvement and health careresearch, and helps demonstrate accountability (CNO, 2005; CRNBC, n.d.; Griffith, 2004;NBSA, 2006). Conversely poor documentationpotentially negatively affects patient care, profes-sional accountability and organisational risk.There are a variety of frameworks for managing nursing documentation in the literature accessedfor this review. These include narrative charting,problem orientated approaches, clinical path- ways, and focus charting. Other tools such as theNorth American Nursing Diagnosis Association(NANDA) nursing diagnoses have also been usedto enhance the quality of nursing documentation(Müller-Staub, Needham, Odenbriet, Lavin, &van Achterberg, 2007).Narrative charting involves documenting interventions and their impact in chronologicalorder covering a set time frame (CNO, 2005;CRNBC, n.d.). When nurses write progress notesusing this method they tend to write a lot mak-ing it difficult to retrieve relevant informationfrom the notes in a timely way. Narrative notesalso tend to be time consuming and repetitiveand may not reflect the nursing process (Hager &Munden, 2008; Mosby, 2006). This framework isnot ideal for our current health care environmenteven though it is still commonly used by many nurses to document the care they provide.One of the potential solutions to the lack of critical thinking and clinical reasoning withincurrent nursing documentation could be the useof a problem-orientated approach. This is not a Hellesø & Ruland, 2001; Idvall & Ehrenberg,2002) with a focus on electronic documentation(Gjevjon & Hellesø, 2010; Häyrinen & Saranto,2009; Kelly et al., 2011; Laitinen, Kaunonen, & Astedt-Kurki, 2010). Several articles were directtranslations from their srcinal language mak-ing some of the information hard to decipherand resulting in the srcinal meaning being lost(Ioanna, Stiliani, & Vasiliki, 2007; Karlsen, 2007).Relevant Australian literature was sparse andcovered issues related to documentation in agedcare settings (Daskein, Moyle, & Creedy, 2009;Pelletier, Duffield, & Donoghue, 2005) and a hos-pital wide nursing documentation project (Tranter,2009). A specific search for New Zealand litera-ture uncovered one publication which outlinedthe SOAP method of documentation (Gagan,2009), and discussed the benefits and advantagesof using this framework. Also present were articlesaimed at providing nurses and other health careprofessionals with extra guidance about differentmethods of documentation and the importantcomponents of legally prudent progress notes(Burgum, 1996; Dimond, 2005b; Griffith, 2004;Grooper & Dicapo, 1995). A variety of guidelinesto assist with development of institutional policiesfor nursing documentation were also located via the internet (College of Nurses Ontario [CNO],2005; College of Registered Nurses of BritishColumbia [CRNBC], n.d.; Nurses Board of South Australia [NBSA], 2006). N URSING   DOCUMENTATION   FRAMEWORKS Quality of documentation is an important issuefor the current nursing workforce in New Zealand.Documentation is defined by the CRNBC (n.d.,p. 5) as ‘any written or electronically generatedinformation about a client that describes the careor service provided to that client’. Nursing docu-mentation is ‘an integral part of safe and effectivenursing practice’ (CNO, 2005, p. 3), and shouldcommunicate observations, decisions, actionsand outcomes related to patient issues and care.Documentation should accurately reflect thehealth status of the patient and the care deliv-ered while reflecting the patient’s perspective of their health and health care (CNO, 2005). Theimportance of accurate timely documentation for  Wendy Blair and Barbara Smith 162 C   N  C   N  C   N  C   N  Volume 41, Issue 2, June 2012 © eContent Management Pty Ltd models for documentation could be used toenhance other structured models to increase theflow through of information from assessment tocare plan (Darmer et al., 2006).The SOAP/SOAPIER method is anotherproblem oriented approach which includes sub- jective and objective assessment data, plan of care,interventions, evaluation and reflection (CNO,2005; CRNBC, n.d.). SOAP notes provide a for-mat that is clear, brief, and supports good prob-lem solving and is a method used by many healthrelated fields including chiropractors (Hamilton,1992), dental hygienists (Jacks, Blue, & Murphy,2008), pharmacists (Kassam et al., 2001), per-sonal trainers (Ball & Murphy, 2008) and doctors,as a means of recording patient care information.Professions using the SOAP/SOAPIER for-mat find it works well for single problem entries(Hamilton, 1992; Jacks et al., 2008; Kassamet al., 2001). However nursing progress notesfrequently need to refer to multiple problems,potentially making this format more difficult touse as it often fails to specify foci for the noteresulting in large entries that are jumbled and dis-organised. Records that use the SOAP format canalso shift the focus from the patient to the diseasethereby perpetuating a disease-focused biomedi-cal model of practice, making it a less desirabledocumentation approach for nursing (Donnelly,2005). In order to counteract this and create a more patient-centred approach Donnelly (2005)suggests that SOAP could be modified to HOAP(history, observations, assessment and plan) inorder to ensure all aspects, including a compre-hensive history are covered.Despite these issues SOAP/SOAPIER seemsto be the preferred method of documentationfor nursing notes within the literature accessed.The SOAP notes format was introduced into ourorganisation in 2004 to try and improve nursing documentation. However it has not proved to beas effective as we had wished due to the tendency for nurses to use SOAP to write a full retrospec-tive shift report rather than a single problem entry.This has resulted in reports that are often missing important information related to specific patientproblems and containing irrelevant informationmaking them wordy and time consuming to read.new approach to documentation as much of theavailable literature about problem-orientatednursing notes is not contemporary ranging from1972 to 2003. In the past problem-orientatednotes have been used to record all elements of patient care (Ehrenberg et al., 1996; Thoma &Pittman, 1972). This system of charting involvesusing a problem sheet to document identifiednursing problems, a care plan that establishedspecific actions for each identified problem, nar-rative notes related to interventions carried out inrelation to the problem, and a flow sheet (obser-vation chart) allowing sequenced recording of tasks related to the patient i.e., vital signs (Thoma & Pittman, 1972).The VIPS model (developed in Sweden) is a problem oriented approach developed in 1991 tosupport the systematic documentation of nurs-ing care while promoting individualised care(Ehrenberg et al., 1996). This model is based onthe concepts of well-being, integrity, prevention,and safety. It consists of two levels: the first cor-responds with the nursing process model (nurs-ing history, status, diagnosis, goal, intervention,outcome, and discharge) and the second withsubdivisions for nursing history, status and inter-ventions. The VIPS model provides a structured way of documenting nursing care that makesnurses think more about how they interact with patients, allowing more of a nursing focus(Bjorvell, Wredling, & Thorell-Ekstrand, 2003).This type of charting can be used to facilitateskilled nursing care and should be considered asa valuable method of recording nursing informa-tion (Thoma & Pittman, 1972). A study exploring the use of the VIPS model with electronic documentation found that thedocumentation was more systematic and that theuse of abbreviations was limited (Rykkje, 2009)making it more legally prudent. However evi-dence suggests that nurses using this model foundit more time consuming, limiting the time they could spend with their patients (Bjorvell et al.,2003). This could add to problems related totime and workload in our current health careenvironment thereby limiting the usefulness of this method of documenting. Despite this many of the concepts contained in problem orientated  Nursing documentation 163 C   N  C   N  C   N  C   N  © eContent Management Pty Ltd Volume 41, Issue 2, June 2012 encourages identification of patient problems andthe ability to link those problems to functionalhealth patterns (Ioanna et al., 2007).Literature suggests that no mater what docu-mentation framework is used nurses requirecontinuing education related to documentationin order to improve and maintain standards.Educational programmes should be readily avail-able and focus on diagnostic reasoning and criti-cal thinking (Darmer et al., 2006; Lee, 2005).Providing suitable timely education creates a chal-lenge in our current system as it is often difficultto get nurses away from the patient care environ-ment for education even thought they learn better when this occurs (Van der Wal, Dalzeal, & Kitzul,2009).It is clear that despite nursing documentationbeing critical to safe and effective care it is some- what unpopular, and is often seen as not being as important as hands on nursing care (Hoban,2003). With increasing budget constraints, infor-mation technology, and expanded nursing rolesinto more specialised areas of practice, nursesrequire a method of documenting that is quick and efficient (Pelletier et al., 2005). With theadvent of small portable computers, electronicrecord keeping is rapidly becoming a viableoption within many health care settings. As a result guidelines are now available to assist nurses with the use of technology in documenting nurs-ing care (CNO, 2005; CRNBC, n.d.) and suit-ably efficient clinical systems and tools shouldallow nurses to provide ‘exceptional documenta-tion’ (Laughlin & Van Nuil, 2003).Using well designed computer technology to document care at the point of contact canimprove the speed and quality of documenta-tion, resulting in more time for direct patientcare (Banner & Olney, 2009; Bosman et al.,2003; Spencer & Lunsford, 2010). Challengesto the use of electronic documentation includethe distances between health care regions; organ-isational challenges related to the need for a userfriendly system; and professional challenges suchas standardising the language used and manag-ing the change from paper to electronic recordsin a constructive and supportive way (Hellesø &Ruland, 2001; Van der Wal et al., 2009). In orderNursing documentation requires a formatthat allows easy access to relevant information.Clinical care pathways, such as an integrated carepathway (ICP), can be developed to provide a standardised form of documentation. They canbe used along side clinical risk and clinical gov-ernance frameworks to manage care for patients with similar diagnoses or problems, in order tooptimise treatment and patient satisfaction using a multidisplinary approach (Hensen, Ma, Luger,Roeder, & Steinhoff, 2005; McGeehan, 2007).ICPs can be used to improve consistency of patientcare while placing importance on the provisionof individually appropriate interventions. They can also act as a single record of care and provide‘explicit standards’ in order to reduce unnecessary variations in interventions (Middleton, Barnette,& Reeves, 2001).Some of the advantages of ICPs includedecreasing or eliminating paperwork, demon-strating the standard of care, and decreasing thetime required to complete documentation allow-ing more time for direct patient care (Armon,MacFaul, Werneke, & Stephenson, 2004).Disadvantages include a lack of individualisedplanning and difficulties with recording unex-pected issues or problems (Lee, 2005). Care path- ways have been introduced and used successfully  within our organisation, but have not provided a solution for our continuing issues related to thelack of documented clinical decision making andevidence of critical thinking in nursing progressnotes.The focus note method of documentation wasdeveloped in the 1990s to combat difficultiesrelated to the SOAP format in a small hospital in America (Lampe, 1997). Focus charting identifiesspecific problems during assessment; care is thendocumented under the headings of data (subjec-tive and objective), actions, and responses (DAR). With this type of documentation a focus or prob-lem is identified and the notes follow a clearly defined format enabling information to be easily located within the progress note (Lampe, 1997). A variation of this type of documentation methodmay assist with issues related to the documenta-tion of clinical decision making and disorganisedprogress notes by providing a framework that