Documentation of Nursing Care in Advanced Home Care

Abstract

Nursing documentation in advanced home care (AHC) is essential in communication between nurses and interprofessionally for evaluation of patient care. Poor documentation could be a threat to high quality care and patient safety. The aim of this study was to describe documentation of nursing care within AHC. Sixty nursing records from two AHC-units in Sweden were collected and a content analysis was performed. The results revealed documentation from a broad spectrum of advanced nursing care, consisting of both planned and acute care. However, the documentation was often fragmented and information sometimes hard to find. Nursing documentation often described caring needs, but lacked interventions and evaluations. Further development and research on nursing documentation and its connection to evidence-based practice within AHC is needed.