Aims: The present study explores how community nurses addressed patient care in the EPR and the comprehensiveness of their documentation.
Background: The need for comprehensive nursing documentation in home health care is considerable and quality is regarded as a prerequisite for continuity of care. Documentation according to the nursing process is considered to be of good quality due to its logical structure. Nurses in home health care face different challenges than nurses in institutionalised care because of long-term patient situations and a focus on chronic illness rather than acute disease.
Design: Retrospective study.
Method: The study was performed on a sample of 91 patient records. Data were analysed in three phases: (1) systematising the unstructured text, (2) structuring the text according to the nursing process and (3) assessing the comprehensiveness using a validated instrument.
Results: The home care nurses documented patient care chronologically along a time axis rather than using a logical structure according to the nursing process. The documentation reflected today's overall emphasis on patient participation, as more than 70% of the notes on nursing status were connected to subjective nursing status. Paradoxically, the nurses showed a lack of attention to the patients' ability to communicate. Only two of 264 documented nursing diagnoses were connected to communication. The comprehensiveness of the documentation, however, was incomplete.
Conclusions: Home health care nurses are attentive to patient participation but fail to address patients' needs with regard to communication. The documentation is incomplete when assessed according to the steps of the nursing process. A question that arises is whether the nursing process may be a limitation for the quality of the nursing documentation.
Relevance to clinical practice: The study contributes to identifying areas of improvement in documentation by nurses in home health care.