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Purposes: This study aimed to compare between electronic medication administration records and paper-based records in the nursing time spent on various activities in a medication round and the medication administration processes followed by nurses in an Australian residential aged care home. It also aimed to identify the benefits and unintended adverse consequences of using the electronic medication administration records., Methods: Time-motion observation, taking of field notes, informal conversation and document review were used to collect data in two units of a residential aged care home. Each unit had one nurse administer medication. Seven nurses were observed over 12 morning shifts. Unit 1 used electronic medication administration records and Unit 2 used paper-based records., Results: No significant difference between the two units was found in the nursing time spent on various activities in a medication round, including documentation, verbal communication, medication administration, infection control and transit. Comparison of the medication administration processes between the electronic and paper-based medication administration records identified a procedural problem which violated the organization's documentation requirement. This problem was documenting before providing medication to a resident when using the paper-based records. It was not observed with the electronic medication administration records. Benefits of introducing the electronic medication administration records included improving nurses' compliance with documentation requirements, freedom from the error of signing twice, reducing the possibility of forgetting to medicate a resident, facilitating nurses to record the time of medication administration to a resident and increasing documentation space. Unintended adverse consequences of introducing the electronic medication administration records included inadequate information about residents, late addition of a new resident's medication profile in the records and nurses' forgetting to medicate a resident due to power outage of the portable device., Conclusions: The electronic medication administration records may not change nursing time spent on various activities in a medication round or substantially alter the medication administration processes, but can generate both benefits and unintended adverse consequences. Future research may investigate whether and how the adverse consequences can be prevented., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Aims and Objectives: To examine the effect of the introduction of an electronic nursing documentation system on the efficiency of documentation in a residential aged care facility., Background: Modern technology has the potential to free caregivers in residential aged care facilities from their burden of paper documentation and allow them more time to care for residents. To date, there is inadequate evidence to verify this assumption., Design: Longitudinal cohort study with work sampling method for data collection., Methods: This study was conducted between 2009-2011; two months before and 3, 6, 12 and 23 months after implementation of an electronic documentation system. A work classification tool was used by an observer to record documentation activities being performed on paper or on a computer by the caregivers., Results: When compared with the proportion of time caregivers spent on documentation in the preimplementation period, personal carers' proportion reduced at three months after implementation. The proportion increased from six months and then dropped at 23 months. Recreational activity officers' proportion increased at three months after implementation. It stabilised at six months and increased again at 12 months. At 23 months, the proportion returned to the preimplementation level. Less than half of the caregivers' time on documentation after implementation was associated with computer-related tasks., Conclusions: Introduction of an electronic documentation system may not necessarily lead to efficiency in documentation for the caregivers. Charting some information items on paper and others on a computer may hinder realization of documentation efficiency., Relevance to Clinical Practice: To optimise the efficiency benefit of electronic documentation in a residential aged care facility, it is not only necessary to automate all nursing forms but also to ensure that the system is aligned with caregivers' documentation practice. Continuous education and mentor support is essential to ensure caregivers' effective usage of the electronic system., (© 2012 Blackwell Publishing Ltd.)

Purpose: To determine whether the introduction of an electronic nursing documentation system in a nursing home reduces the proportion of time nursing staff spend on documentation, and to use this information in evaluating the usefulness of the system in improving the work of nursing staff., Methods: An observational work sampling study was conducted in 2009 and 2010, 2 months before, and 3, 6 and 12 months after the introduction of an electronic nursing documentation system. An observer (ENM) used a work classification tool to record documentation activities being performed using paper and with a computer by nursing staff at particular times for periods of 5 days., Results: Three hundred and eighty three (383) activities were recorded before implementation of the electronic system, 472 activities at 3 months, 502 at 6 months, and 338 at 12 months after implementation. There was no significant difference between the proportion of time nursing staff spent on documentation 2 months before and 3 months after the implementation of the electronic system. Six months after implementation, the proportion of time on documentation increased significantly and after 12 months, settled back to original levels that were recorded in the paper-based system. Over half of the proportion of time on documentation at 6 and 12 months after implementation was spent on paper documentation tasks., Conclusion: Introduction of an electronic nursing documentation system did not reduce the proportion of time nursing staff spent on documentation. This may in part have been a result of the practice of documenting some information items on paper and others on a computer. To reduce the use of paper documentation or to achieve a paper-free documentation environment in this setting, an in-depth understanding of nursing staff's information needs, and documentation workflow is necessary., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Aims: This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation., Introduction: Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings., Data Sources: Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010., Review Methods: A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted., Results: Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality., Conclusion: Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement., (© 2011 Blackwell Publishing Ltd.)

Aim To develop an Australian nursing documentation in aged care ( Quality of Australian Nursing Documentation in Aged Care ( QANDAC)) instrument to measure the quality of paper-based and electronic resident records. Methods The instrument was based on the nursing process model and on three attributes of documentation quality identified in a systematic review. The development process involved five phases following approaches to designing criterion-referenced measures. The face and content validities and the inter-rater reliability of the instrument were estimated using a focus group approach and consensus model. Results The instrument contains 34 questions in three sections: completion of nursing history and assessment, description of care process and meeting the requirements of data entry. Estimates of the validity and inter-rater reliability of the instrument gave satisfactory results. Conclusion The QANDAC instrument may be a useful audit tool for quality improvement and research in aged care documentation. [ABSTRACT FROM AUTHOR]