Background: Quality in nursing documentation facilitates continuity of care and patient safety. Lack of\ncommunication between healthcare providers is associated with errors and adverse events. Shortcomings are\nidentified in nursing documentation in several clinical specialties, but very little is known about the quality of how\nnurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written\nnursing documentation in a psychiatric hospital.\nMethod: A cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument.\nIn 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to\nDecember 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes,\nnursing care plans, progress and outcome reports, discharge notes and information about the patientsââ?¬â?¢ personal\ndetails. The items of N-Catch were scored for quantity and/or quality (0ââ?¬â??3 points).\nResults: The item ââ?¬Ë?quantity of progress and evaluation notesââ?¬â?¢ had the lowest score: in 86% of the records progress\nand outcome were evaluated only sporadically. The items ââ?¬Ë?the patientsââ?¬â?¢ personal detailsââ?¬â?¢ and ââ?¬Ë?quantity of record\nstructureââ?¬â?¢ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these\nitems.\nConclusions: Deficiencies in nursing documentation identified in other clinical specialties also apply to the clinical\nfield of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs\nimprovements to ensure continuity and patient safety. This study shows the importance of the existence of a\nvalidated tool, readily available to assess local levels of nursing documentation quality
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