The documentation practice of perioperative nurses: a literature review

Aims and objective To explore and present the existing knowledge of the documentation practices of perioperative nurses in the operating room. Background Studies demonstrate that the documentation of nursing care provided is important for the continuity of patient care as well as patient safety. Nurses find that documenting their perioperative services is important to the surgical pathway; however, a number of studies indicate that the documentation practices of perioperative nurses are characterised by subjectivity, randomness and poor quality. Design A literature review with a systematic search of scientific material. Method The content of the studies included was analysed using content analysis as suggested by Krippendorff. The materials were acquired by searching electronic databases. The search was performed for the period 1995–2015 and resulted in 12 studies. Results Three general themes were found to be important for perioperative nurses’ documentation practices: (1) the documentation tool must be adapted to the clinical practice; (2) nurses document to improve patient safety and protect themselves legally; and (3) traditions and conditions for documentation. Conclusion Nurses considered documenting their perioperative practices very important. It was of vital importance that the tool used be adapted to the actual clinical practice and to relevant regulations regarding form and content. Nurses’ subjective perceptions of and opinions on the effect of documentation influenced their documentation practices, which were widely governed by habits and traditions. Nurses document to safeguard patients against errors but also to protect their own legal status. Nurses also use documentation as proof of their nursing and as ‘a window’ to gain recognition for their professional practice. Relevance to clinical practice Our review demonstrates that a focus on the documentation traditions of perioperative nurses combined with training, structure and improved technical tools may facilitate the documentation and thereby improve patient safety.