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Nursing documentation: Frameworks and

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Nursing documentation: Frameworks and barriers

WENDY BLAIR AND BARBARA SMITH

NZNO, HWNZ Post Graduate Coordinators Group, MidCentral Health Nurse Governance Council,
Palmerston North, New Zealand
The quality of nursing documentation is an important issue for nurses both nationally and internationally. Nursing docu-
mentation should, but often does not show the rational and critical thinking behind clinical decisions and interventions,
while providing written evidence of the progress of the patient. A number of frameworks are currently available to assist
with nursing documentation including narrative charting, problem orientated approaches, clinical pathways, and focus
notes. However many nurses still experience barriers to maintaining accurate and legally prudent documentation.
A review of nursing documentation of patient care and progress towards achieving outcome goals in our organisation
identified a lack of clear and easy to follow information about the patient’s progress. In order to address with this issue a
project group was established to look at different frameworks for nursing documentation. The aim of the project was to
identify and implement a documentation framework that would encourage critical thinking and provide evidence of the
rationale for nursing actions utilising a problem based approach in order to provide accurate evidence of patient progress.
This paper provides a synopsis of available literature related to the frameworks mentioned above, highlights barriers to
safe, timely and accurate documentation for nurses, and concludes with an explanation of the framework chosen as a result
of this review.

Keywords: nursing documentation; nursing reports; literature review; progress notes

T he quality of nursing documentation is an

important issue for nurses both nationally and
internationally. It is clear from many cases on the
The review of literature sought to identify cur-
rent methods of nursing documentation in order
to identify any that could be used to improve
New Zealand Health and Disability Commissioner the quality of nursing progress notes. A litera-
Website (Health and Disability Commissioner, ture search was performed using CINAHL and
2009) that issues related to poor nursing docu- MEDLINE. Key words used included the follow-
mentation need to be urgently addressed. Different ing; documentation, progress notes, and nursing
nursing documentation methods such as SOAPIE reports. The review focused on documentation
are used to provide frameworks that guide nursing methods, problem orientated documentation,
documentation. However these methods do not barriers to documentation, risk management, and
necessarily meet the documentation needs of busy legal implications. Literature published between
clinical areas in the current health environment 1998 and 2011 was reviewed. Some seminal pieces
because they focus on single problem entries and of literature have been included from 1974 to 1997
patients are often complex with multiple problems. as these provide relevant background informa-
Nursing documentation in our organisation tion. Much of the more recent literature available
has lacked a clear rationale for clinical decisions is in the form of systematic reviews with a focus
and evidence of critical thinking. In order to deal on electronic documentation (Kelly, Brandon,
with this issue a project group was established to & Dicherty, 2011), audit instruments (Wang,
look at different methods of nursing documenta- Hailey, & Yu, 2011), and accuracy of documenta-
tion. The aim of this project was to identify a tion (Paans, Nieweg, Van der Schans, & Sermeus,
method that would encourage critical thinking 2011) which have not been discussed in this paper.
by using a problem based approach. This article Much of the available literature accessed was
provides a summary of the literature reviewed at related to nursing documentation within acute
the commencement of this project and a sum- care settings and originated from Europe (Darmer
mary of the framework chosen as a result of this et al., 2006; Ehrenberg & Birgersson, 2003;
review. Ehrenberg, Ehnfors, & Thorell-Ekstrand, 1996;

160 CN Volume 41, Issue 2, June 2012

 Nursing documentation CN
Hellesø & Ruland, 2001; Idvall & Ehrenberg, continuity of care and reduction of risk has also
2002) with a focus on electronic documentation been raised as an issue in other health related disci-
(Gjevjon & Hellesø, 2010; Häyrinen & Saranto, plines, with social work and physical therapy expe-
2009; Kelly et al., 2011; Laitinen, Kaunonen, & riencing similar challenges to nursing (Delaune &
Astedt-Kurki, 2010). Several articles were direct Bemis-Dougherty, 2007; Reamer, 2005).
translations from their original language mak- Anecdotal evidence suggests that the stan-
ing some of the information hard to decipher dard of nursing documentation is suffering as a
and resulting in the original meaning being lost result of the time pressure that nurses in many
(Ioanna, Stiliani, & Vasiliki, 2007; Karlsen, 2007). clinical environments are experiencing. Current
Relevant Australian literature was sparse and issues include the lack of timely entries, lack of
covered issues related to documentation in aged comprehensive and accurate information, and a
care settings (Daskein, Moyle, & Creedy, 2009; lack of accurate assessment information and fol-
Pelletier, Duffield, & Donoghue, 2005) and a hos- low through care planning. Accurate documenta-
pital wide nursing documentation project (Tranter, tion facilitates communication, promotes nursing
2009). A specific search for New Zealand litera- care, helps to meet professional and legal require-
ture uncovered one publication which outlined ments, aids quality improvement and health care
the SOAP method of documentation (Gagan, research, and helps demonstrate accountability
2009), and discussed the benefits and advantages (CNO, 2005; CRNBC, n.d.; Griffith, 2004;
of using this framework. Also present were articles NBSA, 2006). Conversely poor documentation
aimed at providing nurses and other health care potentially negatively affects patient care, profes-
professionals with extra guidance about different sional accountability and organisational risk.
methods of documentation and the important There are a variety of frameworks for managing
components of legally prudent progress notes nursing documentation in the literature accessed
(Burgum, 1996; Dimond, 2005b; Griffith, 2004; for this review. These include narrative charting,
Grooper & Dicapo, 1995). A variety of guidelines problem orientated approaches, clinical path-
to assist with development of institutional policies ways, and focus charting. Other tools such as the
for nursing documentation were also located via North American Nursing Diagnosis Association
the internet (College of Nurses Ontario [CNO], (NANDA) nursing diagnoses have also been used
2005; College of Registered Nurses of British to enhance the quality of nursing documentation
Columbia [CRNBC], n.d.; Nurses Board of South (Müller-Staub, Needham, Odenbriet, Lavin, &
Australia [NBSA], 2006). van Achterberg, 2007).
Narrative charting involves documenting
NURSING DOCUMENTATION FRAMEWORKS interventions and their impact in chronological
Quality of documentation is an important issue order covering a set time frame (CNO, 2005;
for the current nursing workforce in New Zealand. CRNBC, n.d.). When nurses write progress notes
Documentation is defined by the CRNBC (n.d., using this method they tend to write a lot mak-
p. 5) as ‘any written or electronically generated ing it difficult to retrieve relevant information
information about a client that describes the care from the notes in a timely way. Narrative notes
or service provided to that client’. Nursing docu- also tend to be time consuming and repetitive
mentation is ‘an integral part of safe and effective and may not reflect the nursing process (Hager &
nursing practice’ (CNO, 2005, p. 3), and should Munden, 2008; Mosby, 2006). This framework is
communicate observations, decisions, actions not ideal for our current health care environment
and outcomes related to patient issues and care. even though it is still commonly used by many
Documentation should accurately reflect the nurses to document the care they provide.
health status of the patient and the care deliv- One of the potential solutions to the lack of
ered while reflecting the patient’s perspective of critical thinking and clinical reasoning within
their health and health care (CNO, 2005). The current nursing documentation could be the use
importance of accurate timely documentation for of a problem-orientated approach. This is not a

© eContent Management Pty Ltd Volume 41, Issue 2, June 2012 CN 161
CN Wendy Blair and Barbara Smith

new approach to documentation as much of the models for documentation could be used to
available literature about problem-orientated enhance other structured models to increase the
nursing notes is not contemporary ranging from flow through of information from assessment to
1972 to 2003. In the past problem-orientated care plan (Darmer et al., 2006).
notes have been used to record all elements of The SOAP/SOAPIER method is another
patient care (Ehrenberg et al., 1996; Thoma & problem oriented approach which includes sub-
Pittman, 1972). This system of charting involves jective and objective assessment data, plan of care,
using a problem sheet to document identified interventions, evaluation and reflection (CNO,
nursing problems, a care plan that established 2005; CRNBC, n.d.). SOAP notes provide a for-
specific actions for each identified problem, nar- mat that is clear, brief, and supports good prob-
rative notes related to interventions carried out in lem solving and is a method used by many health
relation to the problem, and a flow sheet (obser- related fields including chiropractors (Hamilton,
vation chart) allowing sequenced recording of 1992), dental hygienists (Jacks, Blue, & Murphy,
tasks related to the patient i.e., vital signs (Thoma 2008), pharmacists (Kassam et al., 2001), per-
& Pittman, 1972). sonal trainers (Ball & Murphy, 2008) and doctors,
The VIPS model (developed in Sweden) is a as a means of recording patient care information.
problem oriented approach developed in 1991 to Professions using the SOAP/SOAPIER for-
support the systematic documentation of nurs- mat find it works well for single problem entries
ing care while promoting individualised care (Hamilton, 1992; Jacks et al., 2008; Kassam
(Ehrenberg et al., 1996). This model is based on et al., 2001). However nursing progress notes
the concepts of well-being, integrity, prevention, frequently need to refer to multiple problems,
and safety. It consists of two levels: the first cor- potentially making this format more difficult to
responds with the nursing process model (nurs- use as it often fails to specify foci for the note
ing history, status, diagnosis, goal, intervention, resulting in large entries that are jumbled and dis-
outcome, and discharge) and the second with organised. Records that use the SOAP format can
subdivisions for nursing history, status and inter- also shift the focus from the patient to the disease
ventions. The VIPS model provides a structured thereby perpetuating a disease-focused biomedi-
way of documenting nursing care that makes cal model of practice, making it a less desirable
nurses think more about how they interact documentation approach for nursing (Donnelly,
with patients, allowing more of a nursing focus 2005). In order to counteract this and create a
(Bjorvell, Wredling, & Thorell-Ekstrand, 2003). more patient-centred approach Donnelly (2005)
This type of charting can be used to facilitate suggests that SOAP could be modified to HOAP
skilled nursing care and should be considered as (history, observations, assessment and plan) in
a valuable method of recording nursing informa- order to ensure all aspects, including a compre-
tion (Thoma & Pittman, 1972). hensive history are covered.
A study exploring the use of the VIPS model Despite these issues SOAP/SOAPIER seems
with electronic documentation found that the to be the preferred method of documentation
documentation was more systematic and that the for nursing notes within the literature accessed.
use of abbreviations was limited (Rykkje, 2009) The SOAP notes format was introduced into our
making it more legally prudent. However evi- organisation in 2004 to try and improve nursing
dence suggests that nurses using this model found documentation. However it has not proved to be
it more time consuming, limiting the time they as effective as we had wished due to the tendency
could spend with their patients (Bjorvell et al., for nurses to use SOAP to write a full retrospec-
2003). This could add to problems related to tive shift report rather than a single problem entry.
time and workload in our current health care This has resulted in reports that are often missing
environment thereby limiting the usefulness of important information related to specific patient
this method of documenting. Despite this many problems and containing irrelevant information
of the concepts contained in problem orientated making them wordy and time consuming to read.

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 Nursing documentation CN
Nursing documentation requires a format encourages identification of patient problems and
that allows easy access to relevant information. the ability to link those problems to functional
Clinical care pathways, such as an integrated care health patterns (Ioanna et al., 2007).
pathway (ICP), can be developed to provide a Literature suggests that no mater what docu-
standardised form of documentation. They can mentation framework is used nurses require
be used along side clinical risk and clinical gov- continuing education related to documentation
ernance frameworks to manage care for patients in order to improve and maintain standards.
with similar diagnoses or problems, in order to Educational programmes should be readily avail-
optimise treatment and patient satisfaction using able and focus on diagnostic reasoning and criti-
a multidisplinary approach (Hensen, Ma, Luger, cal thinking (Darmer et al., 2006; Lee, 2005).
Roeder, & Steinhoff, 2005; McGeehan, 2007). Providing suitable timely education creates a chal-
ICPs can be used to improve consistency of patient lenge in our current system as it is often difficult
care while placing importance on the provision to get nurses away from the patient care environ-
of individually appropriate interventions. They ment for education even thought they learn better
can also act as a single record of care and provide when this occurs (Van der Wal, Dalzeal, & Kitzul,
‘explicit standards’ in order to reduce unnecessary 2009).
variations in interventions (Middleton, Barnette, It is clear that despite nursing documentation
& Reeves, 2001). being critical to safe and effective care it is some-
Some of the advantages of ICPs include what unpopular, and is often seen as not being
decreasing or eliminating paperwork, demon- as important as hands on nursing care (Hoban,
strating the standard of care, and decreasing the 2003). With increasing budget constraints, infor-
time required to complete documentation allow- mation technology, and expanded nursing roles
ing more time for direct patient care (Armon, into more specialised areas of practice, nurses
MacFaul, Werneke, & Stephenson, 2004). require a method of documenting that is quick
Disadvantages include a lack of individualised and efficient (Pelletier et al., 2005). With the
planning and difficulties with recording unex- advent of small portable computers, electronic
pected issues or problems (Lee, 2005). Care path- record keeping is rapidly becoming a viable
ways have been introduced and used successfully option within many health care settings. As a
within our organisation, but have not provided a result guidelines are now available to assist nurses
solution for our continuing issues related to the with the use of technology in documenting nurs-
lack of documented clinical decision making and ing care (CNO, 2005; CRNBC, n.d.) and suit-
evidence of critical thinking in nursing progress ably efficient clinical systems and tools should
notes. allow nurses to provide ‘exceptional documenta-
The focus note method of documentation was tion’ (Laughlin & Van Nuil, 2003).
developed in the 1990s to combat difficulties Using well designed computer technology
related to the SOAP format in a small hospital in to document care at the point of contact can
America (Lampe, 1997). Focus charting identifies improve the speed and quality of documenta-
specific problems during assessment; care is then tion, resulting in more time for direct patient
documented under the headings of data (subjec- care (Banner & Olney, 2009; Bosman et al.,
tive and objective), actions, and responses (DAR). 2003; Spencer & Lunsford, 2010). Challenges
With this type of documentation a focus or prob- to the use of electronic documentation include
lem is identified and the notes follow a clearly the distances between health care regions; organ-
defined format enabling information to be easily isational challenges related to the need for a user
located within the progress note (Lampe, 1997). friendly system; and professional challenges such
A variation of this type of documentation method as standardising the language used and manag-
may assist with issues related to the documenta- ing the change from paper to electronic records
tion of clinical decision making and disorganised in a constructive and supportive way (Hellesø &
progress notes by providing a framework that Ruland, 2001; Van der Wal et al., 2009). In order

© eContent Management Pty Ltd Volume 41, Issue 2, June 2012 CN 163
CN Wendy Blair and Barbara Smith

to make it practical for such packages to be used 25–50% of their time on documentation which
for progress notes, computer terminals would can result in less time spent with patients or work-
need to be readily available to the nurse which ing overtime to complete progress notes (Gugerty
remains a challenge in many New Zealand health et al., 2007; Trossman, 2002). It is clear that
care environments. nurses need to allocate time and use appropri-
Hand written notes have historically been ritu- ate tools for documentation in order to enhance
alistic, lacking in essential information (Wilson, professional practice and patient outcomes (Reed,
1998) and messy making them hard to read. 1991; Wood, 2002).
Electronic documentation may help to allevi- Documentation has both practical and legal
ate problems related to legibility and the use of implications for nursing world wide. Being able
abbreviation in the future (Dimond, 2005a). to document in a clear succinct, legible and
Barriers to electronic documentation include lack legally prudent way can significantly reduce the
of computer experience, slow or poorly func- risk of misunderstanding and negative patient out
tioning equipment, a lack of support from other comes related to poor communication. Nurses
staff, and time taken to log on and off the system need to understand that their documentation can
(Whittaker, Aufdenkamp, & Tinley, 2009). be scrutinised when there has been a complaint
or incident resulting in harm (sentinel event).
BARRIERS TO DOCUMENTATION Investigations of complaints and sentinel events
Nursing documentation has been discussed in are undertaken in New Zealand through courts of
the literature for many years with a wide range law or by the Health and Disability Commissioner
of studies looking at methods and barriers. (New Zealand Government, 1994). Findings
Nurses encounter major barriers to documen- from these investigations are then passed on to
tation including time constraints, mismatches the relevant professional body such as the Nursing
between staffing resources and work load, lack Council of New Zealand and evidence of poor
of clear guidelines for completing documenta- documentation can then be used as evidence for
tion, ambivalence towards documentation, and professional misconduct (McGeehan, 2007).
the bureaucratic systems and institutional policies Clinical records including nursing progress
often associated with keeping accurate documen- notes contain ‘the most central information
tation (Dion, 2001; Meurier, 1998; Owen, 2005; and communication’ about patient care used by
Tingle, 2001). healthcare professionals (Hellesø & Ruland, 2001
These problems with nursing documenta- p. 799), and are one of the main sources of evi-
tion are well publicised (Kärkkäinen & Eriksson, dence used to investigate complaints (Pennels,
2005; Owen, 2005). Anecdotal evidence suggests 2001). In some situations clinical records such
that nurses can view documentation as a time con- as progress notes may be the only record of the
suming nuisance. It is often left until last, result- healthcare professionals’ version of what took
ing in hurried entries that lack depth and detail, place in relation to a patients care (New Zealand
risking the loss of important data and potentially Nurses Organisation, 1998).
leading to poorer patient outcomes. Nursing The time taken for documentation could be
documentation is often deficient, not only gen- better managed by documenting ‘what should be
erally, but for specific types of records such as done’, ‘what has been done’ and ‘the outcomes of
wound and ulcer care (Ehrenberg & Birgersson, that care’, rather than developing lengthy care plans
2003), care of those presenting with chest pain and nursing diagnoses (Burgum, 1996, p. 40) and
(Meurier, 1998), and pain management (Idvall & by documenting throughout the shift rather than
Ehrenberg, 2002). waiting until the end (Hoban, 2003). While it is
Documentation often takes nurses away from clear that frameworks can be used to aid the docu-
the bedside because of the environment and rou- mentation process; however frameworks such as ‘the
tines of the clinical area. Research suggests that nursing process’ could also hinder documentation
nurses in acute care settings can spend up to by making it more confusing and time consuming

164 CN Volume 41, Issue 2, June 2012 © eContent Management Pty Ltd
 Nursing documentation CN
(Ehrenberg & Birgersson, 2003). Nursing docu- FOCUS
S
mentation needs to be streamlined so that it is less A
time consuming. However current literature does A O
not elaborate on how this could be achieved. D
Patients and relatives are now able to access notes A
and read what has been written. As a result nurses Care P
Plan I P
and other health care professionals also need to be
I
more prudent in how they document (Dimond, I
2005a) and ensure that appropriate language is
E E
used and appropriate entries documented. The E
use of abbreviations and acronyms in documenta-
tion is problematic and a clear patient safety issue FIGURE 1: RELATIONSHIP BETWEEN FOCUS CHARTING THE
as misinterpretation within medical and nursing NURSING PROCESS AND SOAPIE
notes can lead to medical/nursing errors (Dimond,
2005a; Kuhn, 2007). Clear accurate documenta- that identified the focus of the entry e.g., mobil-
tion combined with effective communication is ity. This space can also be used to write the letters
an effective method of risk prevention within the A, I and E as a prompt for nurses to record rel-
clinical setting (Tingle, 2001; Wilson, 1998). evant assessment data, nursing interventions, and
evaluation information for each focus thus mak-
TOWARD THE FUTURE: FOCUS CHARTING ing it easy to identify the relevant information.
As a result of this literature review we chose A pilot of this form and the focus charting
to investigate the use of focus charting as the method was carried out within our assessment,
method of documenting nursing notes for our treatment and rehabilitation (AT&R) wards. The
organisation. This method was chosen because similarity between the focus method and SOAPIE
it encourages the clear identification of a focus meant that nurses did not have to learn some-
for the nursing note and provides a clear frame- thing totally new but rather apply their knowl-
work that fits well with the nursing process which edge of the nursing process in a simplified way.
nurses already use. It also provides information Within 2 weeks of beginning staff education 70%
within the nursing notes that is easy to locate as of nurses were successfully using this method of
the reader can go to the appropriate focus and see documentation for their patient progress notes.
the patients’ progress. Two weeks later there was 100% uptake and feed-
An outline of the focus charting method was back from nurses, medical staff and allied health
provided to all nursing staff and after receiv- workers was extremely positive. There had also
ing feedback we modified the method so that been a notable improvement in the standard of
it related more to the nursing process, which is documentation evidenced by audits remaining
foundational to nursing within our organisa- consistently over 95%.
tion. The project group changed the original A demonstration of the effectiveness of focus
‘data, action, response’ (DAR) to ‘assessment, charting was also gained during the pilot project
implementation, and evaluation’ (AIE). The when one of the wards involved had an out break
focus charting method reflects and simplifies the of Norovirus. During previous outbreaks of this
steps in SOAPIE making it easier for nurses to kind it had taken two staff several days to review
document multiple problems accurately. Figure 1 25 sets of patient notes in order to track the out-
below shows the relationship between the nursing break. However on this occasion it took one person
process, SOAPIE and the AIE of focus charting. approximately 3 hours to achieve the same result.
An extra column was then added to the medi- The auditor was able to easily identify all the rel-
cal and nursing note form on the left hand side evant nursing entries by using the focus column to
beside the date column. This ‘focus’ column gave access relevant data related to each patient’s nurs-
nurse a place to document a statement or word ing care through the A, I and E comments along

© eContent Management Pty Ltd Volume 41, Issue 2, June 2012 CN 165
CN Wendy Blair and Barbara Smith

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cat-ch-ing. Vård I Norden, 29(2), 9–13. Received 29 March 2011 Accepted 27 October 2011

N O W AVA I L A B L E
MIXED METHODS RESEARCH IN THE HEALTH SCIENCES
A special issue of Int J Multiple Research Approaches – Volume 5 Issue 1 – ii+142 pages – ISBN 978-1-921348-93-8 – February 2011
Editors: Elizabeth Halcomb (School of Nursing and Midwifery, University of Western Sydney, Sydney, NSW) and
Sharon Andrew (Department of Acute Care, Faculty of Health and Social Care, Anglia Ruskin University, Chelmsford, UK)
Editorial: Dinner is served: A full course of multiple research approaches Designing mixed methods studies in health-related research with
for your health sciences methodological appetite – Michael D Fetters people with disabilities – Thilo Kroll
Writing publishable mixed research articles: Guidelines for emerg- INHospital study: Do older people, carers and nurses share the same
ing scholars in the health sciences and beyond – Nancy L Leech, priorities of care in the acute aged care setting? – Louise D Hickman,
Anthony J Onwuegbuzie and Julie P Combs Patricia M Davidson, Esther Chang and Lynn Chenoweth
Where there is no gold standard: Mixed method research in a cluster Integrating qualitative and quantitative research approaches via the
randomised trial of a tool for safe prioritising of patients by medical phenomenological method – William Paul Fisher and A Jackson Stenner
receptionists – Sally J Hall, Christine B Phillips, Phillip Gray, Amanda Barnard Factors to drive clinical practice improvement in a Malaysian intensive
and Kym Batt care unit: Assessment of organisational readiness using a mixed method
Can focus groups be used for longitudinal evaluation? Findings from approach – Kim Lam Soh, Patricia M Davidson, Gavin Leslie, Michelle
the Medellin early prevention of aggression program – Michael Ungar, DiGiacomo, John X Rolley, Kim Geok Soh and Aisai Bin Abd Rahman
Luis F Duque and Dora Hernandez Child protection workers: What they do – Rebecca O'Reilly, Lauretta Luck,
Beyond the ceiling effect: Using a mixed methods approach to measure Lesley Wilkes and Debra Jackson
patient satisfaction – Sharon Andrew, Yenna Salamonson, Bronwyn Epilogue: From 'should we be?' to 'how are we': Moving forward with
Everett, Elizabeth J Halcomb and Patricia M Davidson mixed methods health research – Sharon Andrew and Elizabeth J Halcomb
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