Nursing Documentation in Hospitalised Adults With an Indwelling Urinary Catheter: Retrospective Study

Abstract

ABSTRACT Is there a relationship between required documentation and patient outcomes? Hospitals routinely conduct chart audits with no evidence that it improves patient outcomes. Using CAUTI as an exemplar, we explored if more complete required documentation is related to improved CAUTI outcomes. No research could be identified directly comparing documentation and patient outcomes. There is secondary evidence that suggests documentation is not related to patient outcomes. A 5‐year retrospective chart review of nursing care documentation in 250 adult medical/surgical and intensive care patients with an indwelling urinary catheter, half with a catheter acquired urinary tract infection and half without, was executed. Required nursing care documentation included catheter continuation reason, catheter care, and catheter care post bowel movement. Differences in total nursing care shifts, total nursing care opportunities, and total bowel movements were examined. A Mann–Whitney U test was performed to compare nursing documentation differences between groups who did and did not develop a CAUTI. Overall non‐compliance with individual or bundled charting requirements was high in those who did and did not develop a CAUTI post catheter placements. Charting compliance was generally comparable in both groups. However, of the three required charting components, a statistically significant group difference for charting compliance was found for cleaning post bowel movements. Other significant group differences included total bowel movements, total nursing shifts, and total care opportunities, with the CAUTI group having significantly more of each. Hospitals expend significant resources to improve charting compliance through audits and feedback. Most of this study's results suggest nursing care documentation is not necessarily associated with patient outcomes, and that process compliance alone should not necessarily be prioritised. However, cleaning post bowel movement is an important CAUTI prevention strategy and should be evaluated to be added to the CDC CAUTI bundle. Continued research is needed to determine if nurse documentation burden could be decreased considering the lack of clearly associated patient impact.