Documentation practices of nurses in long-term care

Abstract

• Documentation of nursing care is an important source of reference and communication between nurses and other health care providers. • This article describes a study of the documentation practices of nurses in a long-term care institution. • Results revealed a number of positive aspects of nurses' documentation practices and areas requiring modification or change which could be facilitated through redesigning the documentation system. • Implications for professional practice are discussed, which include the need for a concise, non-duplicating system of documentation, and the importance of nursing documentation in support of evidence-based practice. © 1999 Blackwell Science Ltd.