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Aims and Objectives: Our aim was to examine the notes produced by nurses, paying specific attention to the style in which these notes are written and observing whether there are concerns of distortions and biases., Background: Clinicians are responsible to document and record accurately. However, nurses' attitudes towards their patients can influence the quality of care they provide their patients and this inevitably impacts their perceptions and judgments, with implications to patients' care, treatment, and recovery. Negative attitudes or bias can cascade to other care providers and professionals., Design: This study used a retrospective chart review design and qualitative exploration of documentation using an emergent theme analysis., Methods: We examined the notes taken by 55 mental health nurses working with inpatients in the forensic services department at a psychiatric hospital. The study complies with the SRQR Checklist (Appendix S1) published in 2014., Results: The results highlight some evidence of nurses' empathic responses to patients, but suggest that most nurses have a style of writing that much of the time includes themes that are negative in nature to discount, pathologise, or paternalise their patients., Conclusions: When reviewing the documentation of nurses in this study, it is easy to see how they can influence and bias the perspective of other staff. Such bias cascade and bias snowball have been shown in many domains, and in the context of nursing it can bias the type of care provided, the assessments made and the decisions formed by other professionals., Relevance to Clinical Practice: Given the critical role documentation plays in healthcare, our results indicate that efforts to improve documentation made by mental health nurses are needed and specifically, attention needs to be given to the writing styles of the notation., (© 2020 John Wiley & Sons Ltd.)

Aims and objections: We aimed to explore the content and language of nursing documentation and gain insight into the internal processes of nurses while notetaking. Background: Documentation is a core competency of mental health nursing, has clinical and ethical importance and is the integral to the efficient and effective care provided to patients. However, issues related to the content and quality of nursing notes continues to be a concern and there remains gaps in our understanding about the internal processes that nurses engage in when writing notes. Design: We used a mixed method design that included a content analysis with note review and interviews. Methods: After watching a video, psychiatric nurses (n = 27) wrote a note and then were interviewed about their note taking process. We used the COREQ guidelines for reporting our data. Results: Participants relied on four main themes when determining what to include in their notes—what happened and what the patient said or did, plus anything different than baseline, and safety concerns. Analyses revealed the presence of bias in the notetaking and participants were not familiar with effective strategies to mitigate these during the documentation process. Lastly, we found that notes are typically consistent in using some of the SOAPE format with notes focused on direct observations and the use of 'facts', while assessment and construction of treatment plans are used to a lesser extent. Conclusions: Our results provide insight into the decision‐making process of nursing staff regarding their documentation practices: overall they appear unaware of the importance of their notes, and believe that capturing the facts about their patients is important, while devaluing their own input and interpretations. Relevance to clinical practice: Our results provide evidence that mental health nurses may need additional training regarding documentation, more specifically about what to include, word choice and bias. [ABSTRACT FROM AUTHOR]

The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of information‐sharing with the interprofessional team and used by other clinicians within the circle of care to guide their decision‐making process. Given the body of evidence highlighting concerns about the quality of nursing documentation and the growing literature demonstrating the presence of bias in healthcare, it is critically important that we examine the impact of this bias in nursing practice. The primary objective of this study was to determine whether clinical decisions and judgements change when nurses read documentation that is either biased or neutral. Using a quantitative, observational study that used surveys to collect data, participants were exposed to two patient vignettes and six clinical notes associated with each patient (notes were written with either biased or neutral language) and asked to make clinical decisions and judgements. Results from 199 nurse participants from a tertiary mental health hospital revealed a notable relationship between the type of notes read (biased vs. neutral) and clinical practice, namely, participants reading biased notes were less likely to offer health teaching when administering pro re nata (PRN) medication for sleep. We also found differences in decision‐making and judgements based on the type of note read depending on years of experience and type of education. The results indicate that biased language in nursing documentation can influence other clinicians' decisions and judgements about patients, thereby indicating a cascade of bias. [ABSTRACT FROM AUTHOR]

Documenting patient care is an important part of mental health services. The documentation is expected to be accurate, relevant, and informative for all future readers as it provides details about patients and the care they are receiving. Language can produce positive or negative emotions in individuals, and these emotions can influence their thoughts and actions. Considering this, nursing documentation can impact the future care of patients. In this study, our aim was to analyse the language and words nurses use when documenting about their patients. Through a qualitative review of notes transcribed by mental health nurses in a forensic setting (n = 55), we explored the adjectives and verbs used across a subsection of their documentation over a three‐month period. More specifically, we identified the most common words used, looked for patterns in use, and examined the emotional weight – or valence – of word choice. Examination of valence scores of the adjectives and verbs in the notes indicates that while nurses describe their patients in a rather neutral manner overall, some words and phrases are ambiguous and/or repetitive, and have the potential to negatively influence the perceptions of the reader regarding the patient. Clinical implications of patient care are discussed in the context of bias management. Nurses need to consider how word choice is linked to negative prosody and the need to provide additional information to avoid ambiguity. Without such care, notes can be subject to misinterpretation by readers leading to undue labels, stigma, and bias. [ABSTRACT FROM AUTHOR]

Aims and objectives: To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process. Background: The ability to accurately document patients’ symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544–1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544–1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122–1131). Design: The project was a mixed‐method, two‐phase study that collected data from two sites. Methods: In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice. Results: Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration. Conclusions: We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation. Relevance to clinical practice: Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases. [ABSTRACT FROM AUTHOR]