Poor Patient Documentation

Poor documentation of care and impact on patient outcome

Clinical Question

This paper addresses whether documentation chart audits can be a good measure in preventing the poor documentation of patient care and its impact on patient assessment outcome. The most important concern is the complications which can result through this negligence in hospitalized pediatric patients. Documentation is a very crucial function of nursing practice, an inadequate documentation leads to challenges and barriers such as insufficient patients care and outcome. Through a one year research by Okaisu, E.M., Kalikwani, F., Wanyana, G. & Coetzee, M., (2014), an initial chart audits of documentation revealed that there was a poor assessment documentation by the nurses. This substandard documentation of assessments was linked to increased post-discharge and in-hospital mortality. However, a current research study conducted by Tiffany F. K., Debra H. B., & Sharron L. D. (2015) disclosed that most of these poor documentation is caused by majority of hospital care units using paper-based nursing documentation to exchange patient information rather than the expected use of electronic method. An effectual, accurate, open, reliable, and timely communication is an essential factor for an accurate documentation of patient care. (Kolanowski, A.,

Since phase two initiated the process of change in culture, the purpose of phase three is to build on the visible changes sustained. Now a literature review on culture, quality/quantity of staff, electronic documentation, was carried out. According to Okaisu, E.M., Kalikwani, F., Wanyana, G. & Coetzee, M., (2014), Necessary systems changes included: (1) redesign testing and implementation of the admission assessment form, (2) change in employment policy, and (3) new focus on creating a healthy working environment based on the American Association of Critical-Care Nurses’ (AACCN)