A cross-sectional study of how cancer nurses document the nursing processes using Digital Health Record (DHR)

STUDY AIM: The aim of the study is to explore how nurses document the nursing processes within a cancer care setting using digital health record (DHR).

RESEARCH QUESTION: How do nurses document the nursing processes within a cancer care setting using DHR?

STUDY DESIGN: A cross-sectional study.

METHODOLOGY: Twenty clinical care records were randomly selected from a large metropolitan hospital in a single medical oncology inpatient ward in Australia. The audit was conducted using the D-Catch instrument to assess the completeness and quality of nursing record using the five elements of the nursing process. Data analysis was conducted in IBM SPSS Statistics version 29.

FINDINGS: The findings from the study showed evidence of high scores across all aspects of the nursing process, both in the completeness of record and an overall positive outcome for the quality of nursing documentation. However, documentation relating to assessment of patients' holistic care needs showed low to zero evidence of any documented record.

IMPLICATIONS ON CARE: This study provided important insight into the documentation of the nursing processes within DHR. The concerns around limited documentation in capturing holistic care needs require attention. The application of D-Catch tool in assessing the nursing process remains useful, as shown in this study; however, its usability within a digital context needs further investigation.