‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care?
Introduction: Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment process which can improve older patient’s outcomes following a hospital admission. Aims: to understand older person nurses experiences of and attitudes to do...
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| Format: | Article |
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SAGE
2016
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| Online Access: | https://eprints.nottingham.ac.uk/38007/ |
| _version_ | 1848795578372194304 |
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| author | Charalambous, Liz Goldberg, Sarah |
| author_facet | Charalambous, Liz Goldberg, Sarah |
| author_sort | Charalambous, Liz |
| building | Nottingham Research Data Repository |
| collection | Online Access |
| description | Introduction: Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment process which can improve older patient’s outcomes following a hospital admission.
Aims: to understand older person nurses experiences of and attitudes to documentation.
Methodology: Semi-structured, in depth interviews of eight qualified nurses at an acute hospital trust. Interviews were analysed using the framework approach to identify key themes.
Results: three overarching themes were identified: gaps, mishaps and overlaps. Gaps refer to information which was missing, inaccurate or inconsistent; mishaps refer to the consequences of these inaccuracies and inconsistencies and overlaps refer to the problem of duplications in recording of information.
Discussion: Older person nurses report many inconsistencies, omissions and duplications in their documentation. This has implications for how nursing contributes to the comprehensive geriatric assessment and the quality of care of older patients.
Recommendations for practice: New ways must be found to minimise and streamline existing documentation to ensure that records are complete, timely and person-centred. Nurses should be mindful that emerging digital technology systems do not create further problems. Ward nurses need to take greater control of development of documentation. |
| first_indexed | 2025-11-14T19:34:19Z |
| format | Article |
| id | nottingham-38007 |
| institution | University of Nottingham Malaysia Campus |
| institution_category | Local University |
| last_indexed | 2025-11-14T19:34:19Z |
| publishDate | 2016 |
| publisher | SAGE |
| recordtype | eprints |
| repository_type | Digital Repository |
| spelling | nottingham-380072020-05-04T18:24:59Z https://eprints.nottingham.ac.uk/38007/ ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? Charalambous, Liz Goldberg, Sarah Introduction: Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment process which can improve older patient’s outcomes following a hospital admission. Aims: to understand older person nurses experiences of and attitudes to documentation. Methodology: Semi-structured, in depth interviews of eight qualified nurses at an acute hospital trust. Interviews were analysed using the framework approach to identify key themes. Results: three overarching themes were identified: gaps, mishaps and overlaps. Gaps refer to information which was missing, inaccurate or inconsistent; mishaps refer to the consequences of these inaccuracies and inconsistencies and overlaps refer to the problem of duplications in recording of information. Discussion: Older person nurses report many inconsistencies, omissions and duplications in their documentation. This has implications for how nursing contributes to the comprehensive geriatric assessment and the quality of care of older patients. Recommendations for practice: New ways must be found to minimise and streamline existing documentation to ensure that records are complete, timely and person-centred. Nurses should be mindful that emerging digital technology systems do not create further problems. Ward nurses need to take greater control of development of documentation. SAGE 2016-12-20 Article PeerReviewed Charalambous, Liz and Goldberg, Sarah (2016) ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? Journal of Research in Nursing, 21 (8). pp. 638-648. ISSN 1744-988X (In Press) Gerontology Older people Nurses as subjects Qualitative Communication nursing documentation frailty geriatric nurse comprehensive geriatric assessment Audit http://journals.sagepub.com/doi/10.1177/1744987116678900 doi:10.1177/1744987116678900 doi:10.1177/1744987116678900 |
| spellingShingle | Gerontology Older people Nurses as subjects Qualitative Communication nursing documentation frailty geriatric nurse comprehensive geriatric assessment Audit Charalambous, Liz Goldberg, Sarah ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? |
| title | ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? |
| title_full | ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? |
| title_fullStr | ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? |
| title_full_unstemmed | ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? |
| title_short | ‘Gaps, mishaps and overlaps’: nursing documentation: how does it affect care? |
| title_sort | ‘gaps, mishaps and overlaps’: nursing documentation: how does it affect care? |
| topic | Gerontology Older people Nurses as subjects Qualitative Communication nursing documentation frailty geriatric nurse comprehensive geriatric assessment Audit |
| url | https://eprints.nottingham.ac.uk/38007/ https://eprints.nottingham.ac.uk/38007/ https://eprints.nottingham.ac.uk/38007/ |