Effective documentation in residential aged care facilities

Abstract

The delivery of effective and appropriate care for older people living in residential care settings depends, in part, on the quality of care documentation available to nurses, care workers and other members of the multidisciplinary team. The documentation of assessment data, care plans and progress recordings are also used in some countries in quality audit processes and to validate claims for funding. Professional leadership in most aged care settings rests largely with nurses and the problem-solving approach to documentation, well established in nursing for some years, is frequently the basis of documentation systems in aged care homes. The benefits to the residents of aged care homes of effective and appropriate documentation could potentially be negated if they are focused less on meeting the needs of residents and more on meeting requirements for quality audit, for funding or for compliance with the tenets of an orthodox approach to documentation, such as that of problem-solving. The need for effective and appropriate documentation in aged care settings is identified in policy statements in most jurisdictions. In most advanced economies investment in developing a plethora of documentation designs and systems, in both paper and electronic formats, is evident. The degree to which this investment contributes to the quality of care for residents and the delivery of care by direct care staff are not yet well established. No previous systematic review concentrating on nursing documentation and quality care outcomes specific to aged care have been identified however two systematic reviews focused on nursing documentation generally have been reported. One systematic review concluded that there appears to be a conflict between documentation to meet the care needs of residents and documentation to meet the needs of management and administration. The reviewers also concluded that nurses in practice now need to be ready to share information systems and information with their patients and with their medical health colleagues. The second systematic review focused on acute care, with the reviewers concluding that there was no measurable evidence to identify the effect of documentation on health outcomes or care quality in acute care settings. Given this lack of clarity surrounding the relationship between documentation, resident outcomes and the quality of care; and the continued investment in both developing new documentation systems and in nursing/care staff time to document care, a systematic review of the available international evidence was considered to be important in contemporary aged care.