Abstract
Background: Nursing documentation is the record of care that is planned and given to patients, yet it is often missing or incomplete. A study of translating results from nurses' assessments of fall risk into tailored interventions using health information technology was used to examine nursing documentation of risk assessment, plans to manage those risks, and interventions to prevent falls.
Objective: The aim of this study was to evaluate the effectiveness of an electronic fall prevention toolkit for promoting documentation of fall risk status and planned and completed fall prevention interventions.
Methods: Nursing documentation related to fall risk and prevention was reviewed in 30% of randomly selected medical records for patients on the eight study units (four intervention units; 5,267 patients) and four usual care units (5,116 patients) during three separate study visits.
Results: Patients on the intervention units were more likely to have fall risk documented (89% vs. 64%, p < .0001). There were significantly more comprehensive plans of care for the patients on the interventions documented, although no differences were found related to documentation of completed interventions compared with usual care unit patient records.
Discussion: The documentation of fall risk status and planned interventions tailored to patient-specific areas of risk was significantly better on the intervention units that used the fall prevention toolkit as compared with usual care units. Improved documentation quality did not extend to the documentation of completed interventions.