Documentation Guidelines Based on Expectation of Documentation Helps Accurate Documentation Among Nurses in Psychiatric Settings

Careful documentation is an integral part of nursing care. It is written information about a client that describes the care or service provided by nurse to client according to their need. Through documentation, nurses communicate their observations, decisions, actions and outcomes of these actions for clients. In the present study an 'ideal documentation guidelines of nurses caring mentally ill client' was developed which can be used by the psychiatric nurses for thorough assessment as well as assessment of the documents. The ideal documentation guidelines consist of four important care areas namely are admission, discharge, selected procedure and specific incident. The study was conducted to compare the expectation of documentation by nurse administrators and actual performance by staff nurses in selected settings. Twenty five administrative nurses and 25 staff nurses were participated in the study. Result showed assessment of majority of actual performance documentation by the staff nurses showed almost proper behaviours and remaining was partially proper. No nurses documentations depict nurses behaviours improper (lowest level) or (highest level) i.e. proper. Same manner administrative nurse also expected a behaviour from the staff nurses that was almost proper behaviours in documentation. Study revealed actual performance with documentation and expectation of the administrators has a significant relationship. Training, CNE etc which might power to improve administrative nurses expectations of behaviours in psychiatric settings but an ideal documentation format or guideline can help nurses to follow proper documentation behaviour which will be based on the ideal documentation guidelines.