Right-sizing Documentation: What the Pandemic Taught Us about Clinical Documentation and Quality of Care

Crit Care Nurs Clin North Am. 2024 Sep;36(3):393-406. doi: 10.1016/j.cnc.2024.04.001. Epub 2024 May 14.

Abstract

Nursing documentation is essential to communicate patient care delivery. This review explores available evidence on the contribution of nursing documentation toward quality care delivery during the COVID-19 pandemic. Nine articles were evaluated for at least one of the 6 factors of quality (eg, safe, timely, equitable, patient-centered, effective, and efficient). Analysis suggests that right-sizing documentation for optimal care quality requires continued efforts to reinforce the value and need of nursing documentation as a primary data source. Continued practice and research efforts are needed to reframe nursing documentation's essential role in benefiting a patient's current and future health care needs.

Keywords: COVID-19; Nursing; Nursing documentation; Quality of care.

Publication types

  • Review

MeSH terms

  • COVID-19* / epidemiology
  • COVID-19* / nursing
  • Critical Care Nursing / standards
  • Documentation* / standards
  • Humans
  • Nursing Records / standards
  • Quality of Health Care*