Standards of Nursing Documentation: Quality Improvement

Effective nursing practice is a fundamental component of the modern healthcare sector as it guarantees its stable functioning and positive outcomes. The complexity of challenges care providers face today, increased diversification of patients’ needs, and the growing demands to the quality introduce the need for sufficient measures to minimize the chance of mistake. Under these conditions, nursing documentation is viewed as of the tools that can help to structure massive amounts of data that health workers acquire every day and process it effectively to achieve existing goals. Unfortunately, regardless of the existing standards of nursing documentation, there are still flaws and issues that should be addressed to attain desired results. It means that quality improvement acquires the top priority for the given sphere as one of the means to facilitate the work of health units and guarantee better treatment outcomes. The major approaches that are analyzed regarding this issue include the use of electronic medical records, audition, and motivating tools, and new methods of data documenting.


Contemporary nursing practice includes multiple components that are vital for the stable work of the healthcare sector. Good documentation is one of these aspects as it is a tool that is used to describe the current health status of a patient, his/her needs, responses to treatment, and other information critical for care providers (Duclos-Miller, 2016). For the establishment of continuity of care, it is vital to possess relevant information about clients and their peculiarities, which means that nursing documentation becomes the central source of data when transferring patients. At the same time, nurses remain responsible for the creation of a safe environment and the provision of appropriate care that will improve the state of individuals (Duclos-Miller, 2016). The inability to maintain documentation can undermine the effectiveness of a nurse, his/her credibility, and deteriorate the image of a hospital (Duclos-Miller, 2016). For this reason, there are multiple tools such as Standards of Nursing Documentation and the American Nurses Association’s (ANA) recommendations on how to work with records to avoid mistakes.

In accordance with the current paradigm, nursing documentations should possess basic a set of basic features. It means that records should be accurate, relevant, accessible, concise, complete, thoughtful, timely, reflective, and readable (Duclos-Miller, 2016; “Tips for great nursing documentation,” n.d.). The presence of these characteristics will significantly reduce the risk of undesired outcomes and failures. At the same time, there are fundamental components of documenting nursing care, such as documentation of the care plan, evaluation of the effectiveness of treatment, and communication between clients and care providers (Duclos-Miller, 2016). These elements are vital for the creation of a beneficial environment and consideration of patients’ needs. For this reason, the majority of quality improvement incentives are also focused on the introduction of positive change to these areas to avoid mistakes and increase the accuracy of data.

The relevant literature related to the problem of quality improvement in the sphere of nursing documentation is united in the opinion that the credibility of records can be achieved by addressing the central aspects of practice and the current issue. Documentation is one of the approaches that help to reduce professional risks and avoid problems or claims. Glen et al. (2015) state that including data about adverse effects, incidents, patients’ refusals, and existing risks will help a nurse to create a background needed for the effective work and minimize the risk of failure associated with the use of corrupted data, maltreatment, or dissatisfaction. It means that recording plays a critical role in the work of the healthcare sector and should be given significant attention to achieve desired outcomes.

Electronic Health Records and IT

Electronic health records (EHRs) and the use of information technologies (IT) are considered one of the methods of quality improvement today. Lavin, Harper, and Barr (2015) state that this documentation tool helps to process data and attain higher levels of patient safety, quality of care, and maximize the overall effectiveness. The digitalization peculiar to the modern world and the need for fast data transfer contribute to the massive implementation of EHR into the work of various health units. In the majority of cases, the employment of electronic records helps to attain a higher level of accuracy and reduce the risk of mistakes (Lavin et al., 2015). For this reason, nurses accept the EHR as a practical tool to improve documenting and attain better outcomes. However, Lavin et al. (2015) also indicate that there is some area for improvement as the software or design of applications might be too complex, cumbersome, or confuse health workers. The existence of these factors might introduce additional uncertainty and precondition flaws in data.

For this reason, there is also a need for continuous EHR improvement as its enhanced functioning is the key to the further evolution of the health care sector and its stable work. Cogitating about the given issue, Lavin et al. (2015) emphasize the importance of the cooperation between nurses and IT staff as one of the ways to upgrade the existing applications and software. Sharing their experiences with vendors and other stakeholders, health workers will able to demonstrate all problems emerging when nursing-related IT actions are preformed and familiarize specialists with the challenges they face (Lavin et al., 2015). The given approach will contribute to the reconsideration of EHR design with the primary goal to make it more convenient and understandable for nurses responsible for recording and maintaining documents. Lavin et al. (2015) also recommend using reflective reasoning and action model that can help to monitor the relevant nurses’ perspectives on the existing technology and share them with IT workers to improve documentation. It will also help to increase interoperability and collaboration between different units.

In such a way, the transformation of electronic health records is viewed as one of the means of quality improvement. Addressing the issue of death by data entry, Weaver and O’Brien (2016) state that the functioning of a special group of informatics leaders and software industry representatives was focused on the creation of recommendations regarding the optimization and improvement of EHR and creation of a specific 2020 framework. One of the basic elements of the offered paradigm is a balance between the generation of knowledge, nurses’ documentation effectiveness, and observation of the standards of quality that will contribute to the improvement of outcomes (Weaver & O’Brien, 2016). In such a way, EHR is considered a potential and promising too that is nowadays a fundamental element of the healthcare sector as it helps to unify processes and align better data exchange, along with the increased accuracy and the ability to avoid mistakes. At the same time, investigators agree in the opinion that the design and functionality of these applications should be improved to ensure that all nurses can understand and use them in their practice (Weaver & O’Brien, 2016).

The enhanced work with big data is also considered one of the possible means of quality improvement. The evolution of evidence-based practice (EBP) is associated with the need to possess and process big data, critical for research, and the creation of new approaches. Under these conditions, Lavin et al. (2015) view EHR as a tool that facilitates big data research by providing accurate and relevant data about patients, their states, and effects treatments cause on them. The increasing use of big data will improve the functioning of the healthcare sector, but, at the same time, it will also enhance the work of electronic records, which introduces the need for their improvement (Weaver & O’Brien, 2016). The introduction of additional options demanded to work with big data better and support EBP, and other research projects is another step in developing health IT and EHR. It will contribute to the better investigation of new cases and the provision of effective care to patients.


Along with the use and upgrade of innovative technologies, investigators also accept the importance of factors traditionally associated with the work of individuals. For instance, Duclos-Miller (2016) outlines the need to engage and motivate staff as one of the possible methods of quality improvement. Statistics show that low motivation levels result in decreased attention, poor performance, and the inability to consider details (Duclos-Miller, 2016). For this reason, motivation acquires the top priority as one of the major facilitators and methods to minimize the number of mistakes associated with documenting. Duclos-Miller (2016) champions the central role of transformational leadership as one of the ways to motivate nurses and train them to maintain records appropriately. At the same time, the creation of a positive and supportive environment in the unit can also be considered a promising quality improvement method that can be used. Motivation is viewed as a component of other activities vital for any hospital, which justifies the need for its improvement.


The current approach to documentation and existing flaws can also be improved by using potent auditing tools. Duclos-Miller (2016) emphasizes the idea that audits and quality improvement processes are vital elements of the work of a health unit as they are interconnected and help to achieve current goals. For instance, a certain problem in documenting might deteriorate the outcomes of a facility and precondition the appearance of new mistakes. The application of discipline-specific audits, along with the additional tools, will help to find the information about the given flaw and primary causes of its emergence (Duclos-Miller (2016). The given data can be used to introduce changes in the existing framework and make mistakes of this sort impossible in the future. It means that audits can be recommended as a potent quality improvement tool that can be used in different settings.

Improved Management of Records

Another quality improvement incentive is associated with better records keeping and structuring. Conducting the research related to this problem, Glen et al. (2015) find that only 12% of all investigated case notes about the work of a surgical ward were without loose pages. Moreover, less than half of all pates had correct patient identifiers and were created within the last 72 hours (Glen et al., 2015). Further analysis shows that the name of a writer and his/her designation can be found only in one-third of all documents (Glen et al., 2015). The given statistics mean that the current state of documenting in some medical units remains unsatisfactory, and there is a need for critical improvement that will help to avoid confusion and attain higher levels of data management.

The solution to the given problem presupposes the use of single admission folders to manage patients’ data and cases. They should contain only the information required for that admission to streamline all notes and make their filling easier (Glen et al., 2015). Investigators come to the conclusion that the introduction of the given method contributed to the improvement across all data sets and the effectiveness of information exchange (Glen et al., 2015). At the same time, the use of labels with patients’ names to mark cases also helped to attain desired outcomes. Concluding, Glen et al. (2015) state that the use of these measures can help to improve the functioning of other facilities and attain desired outcomes along with saving money for some extra equipment or training. Better organization of recording is a possible approach that can be employed by all actors in the healthcare sector.

Education and Training

Finally, all existing sources accept the outstanding role of education and training in quality improvement related to managing health records. For instance, Stewart Doody, and Moran (2017) state that continuous education is vital to sustain positive results and ensure that specialists will remain informed about innovative technologies and how they can be used to improve outcomes. The constant appearance of new software and methods to work with clients’ information means that nurses should be trained on how to work in a new digitalized environment and maintain health records at the appropriate level. It will contribute to the minimization of risk and achievement of better outcomes preconditioned by the absence of corrupted or false data.


Analyzing the problem of quality improvement related to documentation, investigators also note that there can be some barriers that should be considered. Glen et al. (2015) state that costs are the most significant factor that should be taken into account when planning alteration as the financing of a health unit might be insufficient. The use of new technology can be too expensive, which evidences the existence of a systemic problem that should be solved to guarantee the higher quality of records management. At the same time, there is also an opportunity to use less costly measures such as training or adding new folders to attain some improvement and guarantee that care will be provided effectively.


Altogether, nursing documentation is a fundamental aspect of the functioning of the modern healthcare sector. The accuracy of data, its relevance, and thoroughness are vital for the achievement of positive outcomes and the ability to provide care to patients. For this reason, there is much attention devoted to this aspect and means of quality improvement that is discussed in the literature revolving around the topic. The use of EHR and its constant upgrading to meet nurses’ needs is viewed as the central method that can improve cooperation between units, avoid mistakes, and create the basis for the further broad use of innovations. At the same time, the increase in motivation levels, audits, and additional training are also considered effective measures that can help to reconsider the current approach to recordings and guarantee that better outcomes will be acquired.


Duclos-Miller, P. A. (2016). Improving nursing documentation and reducing risk. Brentwood, TN: HCPro.

Glen, P., Earl, N., Gooding, F., Lucas, E., Sangha, N., & Ramcharitar, S. (2015). Simple interventions can greatly improve clinical documentation: A quality improvement project of record keeping on the surgical wards at a district general hospital. BMJ Quality Improvement Reports, 4(1), u208191.w3260. Web.

Lavin, M. A., Harper, E., & Barr, N. (2015). Health information technology, patient safety, and professional nursing care documentation in acute care settings. The Online Journal of Issues in Nursing, 20(2). Web.

Stewart, K., Doody, O., Bailey, M., & Moran, S. (2017). Improving the quality of nursing documentation in a palliative care setting: A quality improvement initiative. International Journal of Palliative Nursing, 23(12), 577-585. Web.

Tips for great nursing documentation. (n.d.). Web.

Weaver, C., & O’Brien, A. (2016). Transforming clinical documentation in EHRs for 2020: Recommendations from University of Minnesota’s Big Data Conference working group. Studies in Health Technology & Informatics, 225, 18-22. Web.