In the last ten years, numerous efforts have been undertaken by health professionals to develop methods of assessing and documenting patient care needs in nursing homes.1 These efforts have focused primarily upon matching patient care needs with nursing care interventions.2 While these efforts have helped to meet the demands of improved documentation for state and federal agencies, efforts to index and sort the defining concepts identifying patient care needs in long-term care have been inadequate.
Without properly defined terms, nurses may interpret the meaning of a patient care need in various ways, thereby reducing the reliability of their documentation. As computer data base management systems develop in long-term care, the need for standardized concept formation will be necessary for accurate data retrieval.
The purpose of this study was to examine the nurses' documentation of patient care needs in a nursing home. We asked questions: Do nurses document patient care needs consistently in the patient's medical record on different documentation tools? What nursing diagnoses do nurses use?
The patient care need selected for this study was urinary incontinence. Urinary incontinence was selected because the costs of urinary incontinence represent 3% to 8% of the total yearly expenditures on nursing home care in this country. This amounts to between $500 million and $1.5 billion per year.3 Incontinence has been reported to affect approximately 50% of all elderly persons in nursing homes and is a leading factor in nursing home placement.4,5 It was, therefore, assumed that urinary incontinence would be a familiar patient care need to the nursing staff.
We hypothesized that nursing documentation of urinary incontinence would vary within the patient's medical record on different documentation tools.
Design: The design selected for this study was a retrospective, descriptive chart audit.
Setting: The setting selected for this study was a 223-bed teaching nursing home facility in an urban community. There were five nursing care units, each of which accommodated 22 to 61 patients. Each unit was staffed by registered nurses, licensed practical nurses and nursing assistants to provide 2.7 to 3.7 hours of care per patient per day (allocated on the basis of acuity). Two nurse practitioners provided the primary patient care in conjunction with an attending physician.
Sampling: Since the researchers wanted to obtain a sample representation of patient medical records in nursing homes, all accessible records on the skilled care and intermediate care units were reviewed. Medical records on the chronic care nursing unit were not included in the study because it was a special care unit.
All of the patients' medical records were located at the respective nurses' stations. Each medical record included the six nursing documentation tools examined, history and physical examination data, laboratory and other evaluative data, and a section from the progress notes.
Data Collection: Data were collected by two gerontology nurse investigators over a three-month period in 1985. Documentation of urinary incontinence was examined on six documentation tools required in one nursing home: nursing admission forms, weekly nursing summaries, state comprehensive patient appraisals, nursing care plans, nursing assistant records and medical problem lists. Urinary incontinence was defined as "a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable."6
Documentation Tools - If a word or phrase with reference to urinary incontinence appeared on the data collection tool , the tool was considered to provide a cue for the nurses to document the presence or absence of incontinence. Each of the tools is described below as either a cueing or non-cueing tool.
Nursing admission forms are jointly completed by both a registered nurse (RN) and licensed practical nurse (LPN). Two types of nursing admission forms were found in the medical records. Those patients who were admitted prior to 1985 had an admission form that included a cue for the nurse to document the presence or absence of incontinence, demographic information, a review of systems, patient needs and a past medical history. This form also provided space to list nursing problems and treatment plans at the time of admission.
Those patients who were admitted after 1985 had a nursing admission form that included cues to fill in the blanks regarding status, health assessment, health history, pattern of daily living, and a review of the physical systems including elimination patterns. However, the word incontinence was not included in the elimination section.
A nursing summary (WNS) was completed weekly by an RN or LPN and utilized to document the patient care needs. Direct questions as to whether the patient was continent or incontinent of urine appeared on the form as a checklist.
The state comprehensive patient appraisal (SCPA) was a patient care management form developed by the state's division of licensing and certification. This form provided a standardized format of patient assessment and care planning for interdisciplinary review, evaluation and documentation. Questions about the presence of incontinence appeared in a section on toileting patterns. This was also the primary patient information document determining the reimbursement rate for patient care in the state this study took place. The formulation of this tool was prompted by the need for a comprehensive patient assessment to be eligible for Medicaid reimbursement for long-term care. The tool provides general guidelines on how to code the data according to definitions provided by the regulatory agency.7 The form was completed every 30 days by an RN or LPN.
Figure 1: A bar chart for the number of times incontinence was documented on each tool
Each patient chart had a nursing care plan form. The care plan was developed by an RN or LPN. The nursing home facility used a standard form on which the nurse developed a plan of care based on the nursing process and the patients' care needs. This tool was not a cueing tool and was updated every two months. Each patient problem was reviewed by the investigators.
The nursing department utilized a nursing assistant charting record (NAR). This tool was a computerized list of nursing care tasks which can be performed by nursing assistants. Nursing assistants initialed the tool indicating that the task was recognized and implemented during their shift. The content of the nursing assistant's record was developed by the RN or LPN using a precoded computed list of items.
Although urinary incontinence was not listed as a computed item, the nurse could select a toilet schedule for the patient if necessary. For example, the form might state "toilet patient every two hours" and the nursing assistant would perform the task. The frequency of references to urinary incontinence and the nursing assistant's initials were examined. This form was updated every 30 days and considered a cueing tool. The medical problem list was a comprehensive list of diagnosed medical problems identified by the nurse practitioner upon admission and updated every 30 days as needed. There were no cues on this tool.
Documentation of urinary incontinence on any of the above tools was recorded. For those tools requiring periodic updating, the documentation appearing in the last 30 days was analyzed.
Data Analysis: Chi-Square Analysis and Contingency Coefficients (C) were calculated to ascertain whether a significant difference existed between the observed number of times urinary incontinence was documented in each patient's chart on the various documentation tools described above. The list of nursing diagnoses accepted at the fifth national Nursing Diagnosis Conference was utilized to taxonomize the content of the nursing care plans.8·9 These diagnoses were then tallied.
The corresponding patients' mean age was 71.8 years. The discharge rate per year was approximately 39% in 1985.
Summary of the Patient Documentation Tools Analyzed
One hundred and ninety-seven patient records were studied. Incontinence was documented most frequently on the weekly nursing summary (WNS), the state comprehensive patient appraisal (SCPA), and the nursing assistant charting record (NAR). Nursing admission forms could not be evaluated because it was later realized that the patients admitted prior to 1983 had no admission database form; admission data were recorded in a narrative note. Urinary incontinence was infrequently mentioned on the medical problem list. The total number of times bladder or bowel incontinence was documented on each of the tools examined is shown in Figure 1 and a summary of the tools is given in Table 1.
Chi-Square analyses showed that the recording of incontinence was significantly different on the documentation tools (x2 (5) = 335 .46; p= .001). When incontinence was documented on one form of a patient's medical record, it was not consistently documented on other forms examined in the same medical record (Table 2). Significant differences were found between the recording of incontinence for the same patient on WNS and SCPA (x2 (1) = 40.0, p= .001); the WNS and NAR (x2 (1) = 38.69; p=. 001); and the SCPA and NAR (x2 (1) = 38.82; ?=. 001).
The contingency coefficients for the four 2x2 chi-square tables were compared. (The upper limit for a 2 x 2 table is 0.71). The associations between the tools in comparisons 2, 3, and 4 were significant. The low C value for comparison 5 was probably due to a small sample; only three records listed urinary incontinence on both the medical problem list and the nursing care plan.
The most frequently documented nursing diagnoses on the nursing care plan are listed in Table 3. Because patient care needs were recounted using a wide variety of descriptive terms, the researchers found it was necessary to "fit" the descriptive terms to the related nursing diagnoses. For example, right hemiparesis was categorized under alterations in mobility, and dementia and confusion were categorized under alterations in thought process. However, many behavioral problems and related conditions identified by the nurses did not conveniently fit under any of the current nursing diagnoses and were classified as "other. "
These problems included depression, hoarding, wandering, demanding, restlessness, belligérance, manipulations, abusive behavior, low motivation, uncooperative behavior, dependency, social isolation, inappropriate family interventions, and unrealistic expectations of family.
In this study, nursing documentation of urinary incontinence varied within the patient's medical record on different documentation tools. Therefore, we accepted our hypothesis as true. ChiSquare analysis showed that the nurses' recording of incontinence varied according to the patient documentation tool being utilized. Overall, incontinence was recorded more frequently on the WNS, SCPA, and the NAR. Significant associations were observed in 2 X 2 comparisons of the WNS, SCPA and NAR.
Furthermore, the most frequently recorded patient care needs were behavioral problems which did not conveniently fit under any of the nursing diagnoses from the fifth national Nursing Diagnosis Conference.
The significant variation among the nurses' recording of incontinence on the different documentation tools deserves serious attention. Several measurement issues are present: the reliability and validity of the documentation tools and the reliability of the nurses who document patient care needs.
It is interesting to note that all three of the tools with the highest occurrences of documented incontinence (WNS, SCPA, and NAR) contained either a word or phrase which prompted (or cued) the nurse to consider incontinence as a patient care need. Neither the nursing care plan, nor the medical problem list (used by nurse practitioners and physicians), contained words to prompt the person documenting.
Do all documentation tools need to be designed to request information regarding certain patient care needs in the nursing home? Do nurses need standardized protocols to prompt specific documentation of patient care needs in the nursing home? If so, how should future protocols and documentation tools be developed? Further information is needed to resolve these measurement issues.
Secondly, nursing diagnoses were not always descriptive of the patient care needs documented on the nursing care plans. Many of the behavioral problems identified by the nurses did not fit under any of the present nursing diagnoses.
Do nurses need an expanded nursing taxonomy to document patient care needs in the nursing home? Can nursing concepts like urinary incontinence be developed to adequately describe patient care needs in the nursing home? Do nurses have an adequate working knowledge of standard nursing diagnoses in the nursing home?
There are several possible explanations as to why urinary incontinence may not have been consistently identified on the different documentation tools.
1. Different nurses may have documented patient information on the different documentation tools at different times.
For example, in this study, documentation on the nursing care plans may have occurred prior to documentation of findings on the state comprehensive patient appraisal or the nursing assistant record. The patient may have been incontinent while in the care of one nurse and not incontinent while in the care of another. Transferring information between patient care providers about potentially episodic patient care needs may not always be successful.
2. When developing nursing care plans, standardized documentation tools like the state comprehensive patient appraisal form may not be utilized as a resource for patient information.
3. Although nurses may be aware of urinary incontinence, the nursing care plan may not always reflect their implemented plan of care.
4. Urinary incontinence may have been perceived as a factor of aging and not a treatable patient care need. For this reason, urinary incontinence assessments may be limited.
The infrequent mentioning of urinary incontinence as a medical problem also suggests that the physicians/primary care providers may not have considered incontinence a treatable condition.
Studies indicate that when registered nurses are educated to treat incontinence and are trained to implement the nursing process to do so, the occurrence of incontinence diminishes significantly.10·" Research is needed to determine the effect that nurses' perception of patient care needs in long-term care has on the documentation of patient problems.
Summary of Data Analysis
Obtainment of reliable information about patient care needs such as urinary incontinence needs further evaluation in the nursing home. Without working definitions of patient care needs in the nursing home, nurses will continue to document needs such as incontinence inaccurately on any standardized nursing documentation tool.
There were several limitations to this study because of 1) the nature of the research design, 2) the use of a convenient sample, and 3) the use of only one nursing home. However, the data suggest that the documentation of patient care needs in nursing homes requires further evaluation.
Documentation procedures that are not reliable should be replaced with well-defined patient care documentation tools. This would facilitate the development of more specific and sensitive geriatric patient care documentation tools in the future.
Long-term care nurses must be encouraged to participate in the future development of the documentation process, particularly in the area of documenting patient care needs. State and federal agencies will continue to depend on nursing documentation as a major source of information about patient care in nursing homes. Therefore, nursing administrators need to develop reliable methods to evaluate nursing documentation.
Secondly, the documentation process should incorporate criteria that assists nurses to 1) transfer patient information into the nursing process and, 2) identify nursing actions that address patient care needs, eg, incontinence, instead of managing them as factors in aging.12 Computerized nursing care plans, like those available from RNact*, could facilitate nurses to write quality care plans on incontinence.
Since the Health Care Financing Administration has computerized its patient information management system for reimbursement, it would behoove nursing to computerize the documentation process of patient care needs in the nursing home setting.13 For example, a computerized assessment tool for incontinence could be developed. This automated assessment tool would guide the nurse through an incontinence assessment and integrate the necessary information for nursing care plans and reimbursement. Similar tools could be developed for other patient care needs.
Further nursing research is needed in the area of computerized nursing documentation tools. Further research is also needed to analyze the following: 1) the specificity and sensitivity of documentation tools, 2) the acquisition of patient information by nursing home nurses for patient care, and 3) the development of nursing diagnoses in long-term care. Further nursing education is recommended to describe realistic nursing actions for dealing with patient care needs such as incontinence and documenting those nursing actions in the patient's medical record. Future development of computerized data-collection tools should be considered for the nursing home.
Most Frequently Documented Patient Care Needs
- 1 . American Health Care Association: Patient Care Management Manual, Long Term Care Facility Improvement Program, Chicago, Illinois, American Healthcare Association, 1983.
- 2. Williamson JW: Assessing and improving health care outcomes: The health accounting approach to quality care. Cambridge, Mass, Ballinger Publishing Company, 1978.
- 3. Ouslander J, Kane R, Vollmer S, et al: Technologies for managing urinary incontinence. (Case Study 33). Washington DC, Office of Technology Assessment, July 1985, p 5.
- 4. Jewett MAS, Femie GR, Holhday PJ: Urinary dysfunction in a geriatric long term care population. Prevalence and patterns. J Am GeriatrSoc 1981; 29:211-214.
- 5. Yamell JWG, St Legar AJ: The prevalence, severity and factors associated with urinary incontinence in a random sample of the elderly. Age Ageing 1979; 8:81-85.
- 6. Baltes P, Bradley WE, Glen E, et al: Standardization of terminology of lower urinary tract function. Urology 1977; February 9(2):237-241.
- 7. Maryland Appraisal of Patient Progress, Baltimore, Maryland. State of Maryland Department of Health and Mental Hygiene, 1982; pp 1-25.
- 8. Kim MJ, McFarland GK, McLane AM: Pocket Guide to Nursing Diagnosis. St. Louis, CV Mosby Company, 1984.
- 9. Carpenito U: Nursing Diagnosis: Application to Clinical Practice. Philadelphia, JB Lippincott, 1983.
- 10. Miller A: A study of the dependency of elderly patients in wards using different methods of nursing care. Age Ageing 1985; 14:132-138.
- 11. Long ML: Incontinence. J Gerontol Nurs 19xx; 11(0:30-41.
- 12. McCormick KA, Burgio KL: Incontinence: An update on nursing care measures. J Gerontol Nurs 1984; 10(10): 16-23.
- 13. McPhillips R: Keynote address: The health care delivery system information requirements and computer technology. Computers in Nursing 1987; 5(5):89-93.
Summary of the Patient Documentation Tools Analyzed
Summary of Data Analysis
Most Frequently Documented Patient Care Needs