Background Documentation of mental health care is a critical component of nursing practice. Despite being identified as playing a critical role, researchers continue to question the quality of nursing documentation and missing and/or inaccurate information. Purpose Our aim is to explore the content of nursing documentation among mental health nurses providing care to forensic inpatients. Methods Using a constructed semi-grounded emergent theme approach for data analysis, we reviewed the types of activities, subjects, and interactions described within nursing notes and identified themes of the content. Results Our results demonstrate that nursing documentation could be categorized into one of seven themes: interactions, food, activities, sleep, mental health, physical health and hygiene. These areas were not consistent with the recommendations from nursing bodies in Canada, specifically the areas of assessment, planning, implementation, and evaluation. Furthermore, missing in the nursing notes is context. Conclusions The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.
Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study
