Compliance between registered nurses’ clinical judgment and documentation in homecare for older patients with COPD: A multiple case study

Abstract

Registered nurses (RNs) play a crucial role in the clinical judgment (CJ) and documentation of the health conditions and the healthcare of patients diagnosed with chronic obstructive pulmonary disease (COPD). Using a multiple case study approach, the aim of the present study was to explore and describe RNs’ CJ in homecare visits for older patients with COPD as they appeared in the electronic patient records (EPRs) and how well the content corresponded to what the RNs explained verbally was important to report. Data were collected through observations of 16 homecare visits, interviews with RNs, and retrospective reviews of EPRs. The study is reported in accordance with COREQ. Quantitative and qualitative content analysis revealed that the RNs’ CJs in homecare visits were represented only to a small extent in the documentation in the EPRs. The documentation was mainly about procedures and tasks performed and did not correspond to what the RNs explained verbally was important to report. This knowledge contributes to improvements to ensure patient safety in this research field.