Abstract

Good quality documentation is an essential component of nursing practice and is vital to the efficient and effective are provided to patients. Improper language, word choice and style in a nursing note can mislead the reader and leave room for bias and misunderstanding of the patient. The objective of this study was to explore the quality of nursing notes by examining word choice and content of documentation from an inpatient mental health setting. Twenty-six nurses were presented with video of a patient-nurse interaction and asked to document the interaction as if they were the nurse in the scenario. Completed notes were analyzed and dissected to examine word choice, content, and writing style. Results indicated that most participants commented on mental health signs and symptoms but did not document on hygiene and sleep. Every note mentioned the interaction between the patient and nurse, and mental health. Examination of valence scores of the adjectives and verbs in the notes indicates that most nurses describe their patients in a rather neutral manner. Taken together, there is an opportunity for improvement in the language and content of nursing documentation to elevate the accuracy and usefulness of nursing documentation and thereby support the proper care of patients in an inpatient mental health setting.