Theoretical Framework In Nursing Documentation

Ideally, nursing documentation is a reflection of the quality of care given to patients. Unfortunately, nursing documentation has been failing to meet recommended standards (A. Prideaux, 2011). The purpose of this study is to elucidate the extent to which nurses adhere to the SOAPIE or ADPIE theoretical framework in nursing documentation.

A high percentage of nurses used the ADPIE framework (35.5%), compared to those using the SOAPIE framework (17.3 %). However, majority of nurses used methods that were unclear (57.3%). With a low of 2.7% using other methods of documentation. Such as narrative charting, focus notes, clinical pathways, DAR, pie (Blair & Smith, 2012). The ADPIE method is the preferred method required by the studied hospital.

Also, only 24.2% of nurses reported nursing diagnosis that corresponds to current medical diagnosis. Similarly, a study conducted at a hospital in western Jamaica by Blake-Mowatt, Lindo and Bennett (2013), revealed similar results. She found that, “only 26% of the records had nursing diagnosis, which corresponded to the current medical diagnosis” (p.1). It was observed that most nurses seem to have difficulties and were not knowledgeable in formulating a nursing diagnosis properly and keeping up to date with the latest NANDA list. This can be due to other factors such as heavy workload which contribute to insufficient time to document

Similarly, Ofi, et al. (2012) concur that, most nurses disagreed or were undecided with inclusion of change the in clients’ condition. Equally important, the outcome of the patient determines the effectiveness of the nursing interventions. Unexpectedly, out of the interventions recorded medication administration was the most common intervention done (28.3%), followed by vital signs (18.8%) charted by the nurses. While safety measures (2.2%) and other department eg MRI (2%) were the least recorded interventions. Vital signs should be the most recorded intervention, especially before administration for certain medications for example, narcotics and antihypertensives. Interventions not documented will have no evidence to support nursing care given. Since what is not documented, is not