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5.7 Findings from Analysis of Nursing Notes
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Chapter 5 Findings
The analysis of the residents’ sets of documentation involved conducting a
content analysis on each resident’s nursing assessment, care plan and daily
nursing notes. Each resident’s set of documents was analysed using the
documentary analysis audit tool designed from the concept analysis (Appendix
9).
The findings presented here are reported under the headings used in the
documentary analysis tool. It is important to acknowledge that the data in this
section relate only to documented care and that documented care may not fully
reflect the actual care given.
Overall it was found that very few residents actually had a “careplan” (a set of
documentation including an assessment of their needs, a plan to meet their needs,
interventions needed to fulfil their needs and an evaluation of the plan of care
with re-assessment as required). Some had assessment documentation (n=14) but
were without any plan of care, and many just had the traditional one or two page
“kardex” and masses of daily notes (n=8). Many of the residents’ original
admissions pages were old and barely legible – they had not been updated from
their admission (some admissions were seven years previously) and were still in
use. No scientific assessments for pressure ulcers, dependency, falls risk or
nutrition were in use. “Sexuality/individuality” assessment sections had biro lines
drawn through and some nurses had written “not applicable” (n=14) on this
section.
The findings from each element of the documentary analysis will now be
presented: Element 1: Resident is self-governing, self-ruling, self-determining.
Element 2: Care plans are negotiated and family are involved. Element 3:
Residents delegate care needs. Element 4: Residential unit has an atmosphere of
openness, motivation and flexibility. Element 5: Values and beliefs of staff are
non-paternalistic (positive in relation to older people). There is an ethos of
maintaining dignity. Element 6: There is open and respectful communication
between residents and staff and sharing of information. Element 7: There is