Evidencing specialist rehabilitation nursing through documentation.

Abstract

All nurses, regardless of specialty, are required to maintain accurate, comprehensive and timely documentation of assessments, planning, decision making, actions and evaluations. As specialist rehabilitation nurses, the ability to accurately articulate the contribution of nursing care to the rehabilitative process is vital in order to validate the provision of rehabilitation nursing care and their contribution to the interdisciplinary team. Following an audit of nursing documentation, it was evident that despite a number of interventions to educate our nurses on documentation, there was a deficit in the ability of our nurses to articulate the need for and provision of skilled rehabilitation nursing. The documented nursing interactions during the project period did improve slightly over time. The development of the resource did have an effect in increasing documentation in some units. Ongoing improvement has relied on NUM and educator commitment to embed the use of the resources consistently.