Journal Review: Documentation presents challenges at hospices

Documentation presents challenges at hospices

Standardization required throughout industry

Patient care is always the hospice nurse's first priority rather than documentation, but in today's legal and regulatory environment, documentation of all aspects of nursing care is critical. A study of nursing documentation practices throughout 16 midwestern hospices shows a wide variation of standards and practices.¹

Documentation is a key factor in supporting consistency and quality of patient care in the hospice setting, but variances between providers will make quality improvement measures and adoption of evidence-based practices difficult to manage as the industry moves to comply with new Conditions of Participation.

The authors state that uniformity in key practice indicators and patient outcome measures in documentation systems are needed to improve quality and consistency of care in hospices. The authors also recommend standardization of documentation systems and language to facilitate research in the hospice setting.

Accuracy of documentation can be called into question when information in the same record seems to contradict itself. In one example cited by the authors, a nurse documented that "patient denies pain" and "patient unresponsive" in the same visit. Another challenge is the use of different terms to describe symptoms, for example, "abdominal pains" and "cramps." The authors identify resources for hospices to use in developing standards for documentation and recommend further study by hospice industry organizations.

Reference

1. Bergen-Jackson K, Sanders S, Herr K, et al. Determining community provider practices in hospices: The challenges of documentation. J Hosp Palliat Nurs 2009; 11:334-341.

RESOURCES

The following articles offer guidance for standardized language to use in patient documentation:

Moorhead S, Clarke M, Willits M, Tomsha KA. Nursing outcomes classification projects across the care continuum. J Nurs Care Qual 1998; 12:52-63.

Moorhead S, Johnson M, Maas M, eds. Nursing Outcomes Classification (NOC). Fourth ed. Philadelphia, PA: Elsevier; 2007: 852-853.

Bulecheck GM, Butcher HK, McCloskey Dochterman J, eds. Nursing Interventions Classification (NIC). Fifth ed. Philadelphia, PA: Elsevier; 2007:815.

Bakken Henry S, Mead C. Nursing classification systems: necessary but not sufficient for representing "what nurses do" for inclusion in computer-based patient record systems. J Am Med Inform Assoc 1997; 4:222-232.