Accurate nursing documentation is fundamental to communication and is a legal requirement. However, nursing documentation is often identified as incomplete, inaccurate and time consuming. To facilitate nursing documentation, a newly developed critical pathway was introduced and pilot tested in the PICU in WA, in 2002. The documentation included a standardised nursing care format (seven categories) and a variance record. The
documentation was complemented by 16 nursing care guidelines of specific nursing care (e.g. care of the ventilated patient). A retrospective study was conducted, 1 year after implementation, to assess the adequacy of the use of the nursing documentation. A random review of 45 patients' charts (10%), was performed using an audit tool. The tool was developed and refined from a pilot review of five patients' charts. Results demonstrated that accuracy of nursing care format on average was 70%, but varied amongst categories. Accuracy of documentation was 93% for baseline, 80% for skin and hygiene, 76% for family needs, 65% for central nervous system, 64% for respiratory, 61% for fluid and nutrition, 50% for central venom system, and 26% for patients specific needs. Utilisation of the nursing care guidelines was correctly documented in the nursing care format in 35% of the time. Agreements between registered nurses, clinical nurses, and casual/agency nurses was good (ICC =0.87).
In summary, accuracy of nursing documentation fell below standards resulting in potential legal implications. Further education of staff, changes for clarification of the documentation, and re-evaluation are recommended.