Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment
Aim: To compare nurses’ and physicians’ documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. Method: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS‐AC) instrument was co...
Published in: | Scandinavian Journal of Caring Sciences |
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crwiley:10.1111/j.1471-6712.2007.00534.x 2024-06-02T08:09:22+00:00 Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment Jensdóttir, Anna‐Birna Jónsson, Pálmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne‐Soveri, Harriet Schroll, Marianne Grue, Else Björnsson, Jan 2008 http://dx.doi.org/10.1111/j.1471-6712.2007.00534.x https://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111%2Fj.1471-6712.2007.00534.x https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1471-6712.2007.00534.x en eng Wiley http://onlinelibrary.wiley.com/termsAndConditions#vor Scandinavian Journal of Caring Sciences volume 22, issue 3, page 341-347 ISSN 0283-9318 1471-6712 journal-article 2008 crwiley https://doi.org/10.1111/j.1471-6712.2007.00534.x 2024-05-03T11:58:52Z Aim: To compare nurses’ and physicians’ documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. Method: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS‐AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. Findings: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40–60% of the nurses’ reports and 80–97% of the physician’s reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85–96% by the physicians . Cognitive function was recorded in only 30–40% of the cases. Conclusions: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS‐AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care. Article in Journal/Newspaper Iceland Wiley Online Library Scandinavian Journal of Caring Sciences 22 3 341 347 |
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Wiley Online Library |
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English |
description |
Aim: To compare nurses’ and physicians’ documentation of geriatric issues and explore double documentation and undocumented areas of importance in an acute care setting in two Nordic countries. Method: 158 participants, aged 75+, of whom the Minimum Data Set for Acute Care (MDS‐AC) instrument was conducted at admission and from which 56 variables were taken in comparison with notes from patient records documented by nurses and/or physicians in two acute care hospitals, in Finland and Iceland. Findings: Documentation of the impairment of personal Activities of Daily Living (ADL) was missing in 40–60% of the nurses’ reports and 80–97% of the physician’s reports. Even poorer was the documentation of the impairment of Instrumental Activities of Daily Living (IADL), of which 75% was not reported by the nurses and 85–96% by the physicians . Cognitive function was recorded in only 30–40% of the cases. Conclusions: The traditional patient record in acute care setting lacks several variables of functional abilities of the older patients. Nurses took more responsibility in the documentation of functional abilities, compared with physicians, but they could improve. Using a standardized instrument such as the MDS‐AC can improve documentation and make a basis for a clearer delineation in responsibilities for documentation between nurses and physicians and thereby improve outcome of care. |
format |
Article in Journal/Newspaper |
author |
Jensdóttir, Anna‐Birna Jónsson, Pálmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne‐Soveri, Harriet Schroll, Marianne Grue, Else Björnsson, Jan |
spellingShingle |
Jensdóttir, Anna‐Birna Jónsson, Pálmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne‐Soveri, Harriet Schroll, Marianne Grue, Else Björnsson, Jan Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment |
author_facet |
Jensdóttir, Anna‐Birna Jónsson, Pálmi Noro, Anja Jonsén, Elisabeth Ljunggren, Gunnar Finne‐Soveri, Harriet Schroll, Marianne Grue, Else Björnsson, Jan |
author_sort |
Jensdóttir, Anna‐Birna |
title |
Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment |
title_short |
Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment |
title_full |
Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment |
title_fullStr |
Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment |
title_full_unstemmed |
Comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment |
title_sort |
comparison of nurses’ and physicians’ documentation of functional abilities of older patients in acute care – patient records compared with standardized assessment |
publisher |
Wiley |
publishDate |
2008 |
url |
http://dx.doi.org/10.1111/j.1471-6712.2007.00534.x https://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111%2Fj.1471-6712.2007.00534.x https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1471-6712.2007.00534.x |
genre |
Iceland |
genre_facet |
Iceland |
op_source |
Scandinavian Journal of Caring Sciences volume 22, issue 3, page 341-347 ISSN 0283-9318 1471-6712 |
op_rights |
http://onlinelibrary.wiley.com/termsAndConditions#vor |
op_doi |
https://doi.org/10.1111/j.1471-6712.2007.00534.x |
container_title |
Scandinavian Journal of Caring Sciences |
container_volume |
22 |
container_issue |
3 |
container_start_page |
341 |
op_container_end_page |
347 |
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1800755064635129856 |