The Significance of Appropriate of Documentation of Vital Signs by Nurses

The monitoring of vital signs is a crucial component of nursing care. Proper documentation of vital signs by nurses is important for noble medical communication because it offers a precise mirror image, variations in conditions, relevant patient data required in supporting the various clinical teams so that they can deliver great care to patients.

Running Head: DOCUMENTING OF VITAL SIGNS BY NURSES
The Significance of Appropriate of Documentation of Vital Signs by Nurses
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DOCUMENTING OF VITAL SIGNS BY NURSES
Abbreviations
ACSQHC - Australian Commission on Safety and Quality in Health Care
NSQHS - National Safety and Quality Health Service

DOCUMENTING OF VITAL SIGNS BY NURSES
The Significance of Appropriate of Documenting of Vital Signs by Nurses
Introduction
The monitoring of vital signs is a crucial component of nursing care (Rose & Clarke,
2010). While in nursing school, nurses are taught the necessity of checking the blood pressure
of a patient, pulse, temperature and respiration because they are important in the
identification of clinical deterioration. As such, those parameters need to be measured
consistently and documented accurately (Rose & Clarke, 2010). The mentioned parameters
are supposed to be the most consistent information in the chart of a patient yet they are not. A
number of studies reviewed showed that vital signs are not steadily documented, assessed or
interpreted. As a result, the lapses hinder timely and appropriate interventions for
deteriorating patients (Rose & Clarke, 2010). Proper documentation of vital signs by nurses is
important for noble medical communication because it offers a precise mirror image,
variations in conditions, relevant patient data required in supporting the various clinical teams
so that they can deliver great care to patients (Hayter & Schaper, 2015). Appropriate
recording offers adequate proof of care and it is a legal requirement in nursing field (Akhu-
Zaheya, Al-Maaitah & Bany Hani, 2017). As a way of fostering proper documentation
practices in healthcare amenities, the ACSQHC started a different project geared towards
improving the response to patient outcomes in 2009. Among the major aims of the program
was to establish an evidence-based adult chart so that it aids the pointing out of patient
deterioration as well as encouraging action in relation to detected physiological anomalies.
Standard 9 of the NSQHS attributes poor recording of vital signs and wrong interpretation of
the signs to the manner in which surveillance charts are utilized, (ACSQHC, 2009). The
objective of this analysis is to evaluate the significance of documenting vital signs
appropriately by nurses in relation to determining deteriorating patients. This will be
achieved by reviewing the available literature on the mentioned topic.

DOCUMENTING OF VITAL SIGNS BY NURSES
Background
Documentation of vital signs assists in dictating treatment, management decisions as
well as indicating the physiological disorder of a patient (Keene et al., 2017). Keeping good
records play a key role in the wellbeing of patients because proper recording acts as a mirror
image of the standard of care accorded to the patients (Keenan et al., 2013). Clear and
accurate records for each patient simplifies the handover process between one team of nurses
and the next. It also acts as a legal significance in that in the event of any arising complaints,
the nursing records usually act as the only proof that the nurse in question fulfilled his/her
duty of care to the patient (Keenan et al., 2013). Therefore, the patient’s nursing records
usually provide an accurate account of the treatment and care provided, and it allows good
communication among nurses (Keenan et al., 2013). Documentation is usually done on
observation charts, manual sheets and electronic health record flowsheets (Collins et al.,
2013). The main vital signs that are usually assessed include pulse, temperature, respiration,
oxygen saturation, blood pressure, urine output, pain and level of consciousness (Bayoumi et
al., 2017). Proper documentation of the mentioned parameters assists in delivering great care
to patients as well as response to observed physiological abnormalities.
Review of the Literature
A wide range of studies was assessed as part of the literature review. All pertinent
findings were then categorized in accordance to the following themes: significance of
appropriate documentation in fostering the delivery of great care to patients, level of staff
compliance with vital signs documentation systems, barriers to proper documentation of vital
signs and ways of enhancing proper documentation.
The significance of Appropriate Documentation in Fostering the Delivery of Care to
Patients

DOCUMENTING OF VITAL SIGNS BY NURSES
The literature highlighted the importance of appropriate documentation in fostering
the delivery of great care to patients (Keene et al., 2017). According to a study conducted by
(Mok et al., 2015), the observation of vital signs is crucial in detecting and acting upon
worsening with the aim of reducing adversarial occurrences such as cardiac arrest. The
observation of vital signs is crucial in nursing such that in some health care facilities, non-
registered nurses are tasked with monitoring patients. Qualified employees play the role of
interpreting the recorded data to oversee the recorded data, and they report any abnormal
values (Mok et al., 2015). The studies indicated that the recording of vital signs is crucial in
health care facilities because of high-quality documentation influences clinical decision-
making processes (Keene et al., 2017). According to (Keene et al., 2017), vital signs
documentation are used by the Modified Early Warning Score (MEWS) in the classification
of the seriousness of a patient’s physiological disorder as well as in detecting the
deterioration of patients. However, one of the studies highlighted that the eminence of
nursing recording of data is still a major challenge in the health care industry and thus a
betterment in healthcare governance is paramount (Dehghan et al., 2013).
On the other hand, a study by (Steven, Israelsson & Nilsson, 2014) indicated the
limitation of knowledge regarding the documenting of vital signs using electronic systems. In
the research conducted by (Stevenson, Israelsson & Nilsson, 2014), the examination of
crucial signs recorded in the electric systems of individuals that had cardiac arrest problems
indicated lack of completeness. It was evident that fragmentation of crucial signs was done
on different subdivisions of the electronic health records thus displaying major gaps in the
demonstration of vital signs using the electronic system. That according to (Stevenson,
Israelsson & Nilsson, 2014) amounted to the threatening of the security of patients.
Level of Staff Compliance with Vital Signs Documentation

DOCUMENTING OF VITAL SIGNS BY NURSES
According to the (ACSQHC,2009), surveillance charts are the chief tools in
documenting data on vital signs thus having a crucial role in the pointing out of the patients
who are at risk. However, despite the crucial role played by observational charts, vital signs
are not always recorded or measured. Studies have shown an increased focus on the use of
observational charts to aid in the identification of patients who are deteriorating. This is
evident with the efforts put internationally and within Australia in revising and improving
charts so that specific factors can be integrated in them (ACSQHC, 2009). The effectiveness
of a surveillance chart requires adjustments regarding the identification of the patients’
deteriorating measures such as physiological measures that predict critical illness or serious
adverse events. It should display information simply so that easy and early identification of
deteriorating is facilitated. However, despite the efforts being put in place in improving the
role played by observational charts, some nurses still overlook some parameters while
recording vital signs. In a study conducted by (Watkins, Whisman & Booker, 2015), the
nurses interviewed shared that continuous surveying of vital signs is crucial because it aids in
improving patient safety. According to (Watkins, Whisman & Booker, 2015), the response of
nurses to abnormal vital signs is considered as the greatest contributor to patient safety
because it creates room for timely recognition of initial patient deterioration. Patient safety is
attained through proper documentation, correct elucidation of data and acknowledgement of a
problem (Watkins, Whisman & Booker, 2015). The research by (Watkins, Whisman &
Booker, 2015) highlighted the routine adopted in recording vital signs. The nurses
interviewed shared that crucial signs are measured thrice a day. Majority of the nurses agreed
that pulse and blood pressure were frequently recorded. Therefore, it was evident that nurses
were the ones who decided the vital signs that needed to be recorded depending with the kind
of clients that they were caring for despite the existence of vital sign recording standards
(Watkins, Whisman & Booker, 2015). In research conducted by (Linder, Schnipper &

DOCUMENTING OF VITAL SIGNS BY NURSES
Middleton, 2012), it was observed that EHR-assessed quality dependent highly on the kind of
documentation done by physicians. This is because the study showed that physicians who
utilized structured EHR documentation had high quality of care compared to those that
dictated their data. However, there is still concern regarding those nurses that do not conduct
vital signs documentation regularly.
Barriers to Proper Documentation of Vital Signs
Nursing documentation is considered an important component in ensuring high-
quality of patient care (Akhu-Zaheya, Al-Maaitah & Bany Hani, 2017). As such,
documentation should always be complete and nurses should adhere to the standards
provided for the purpose of ensuring safety and quality of the clinical services (Akhu-Zaheya,
Al-Maaitah & Bany Hani, 2017). However, nurses continue to encounter serious challenges
in relation to documentation (Blair & Smith, 2012).
According to the research by (Blair & Smith, 2012), nurses consider documentation as
a time-consuming exercise, in that most of the times, it is usually done when the shift is
almost over leading to cases of incompleteness thus contributing to poor patient outcomes.
Additionally, there is usually some level of deficiency on specific types of records relating to
ulcer and wound care as well as those patients presenting chest pains (Blair & Smith, 2012).
According to (Blair & Smith, 2012), in as much as documentation is good, it always
interferes with the routines of the clinical area because it takes nurses away from the bedside
of patients that results in minimal time spent with patients and in other cases, nurses are
forced to work overtime so that they can complete progress notes. Therefore, (Blair & Smith,
2012) suggests that nurses should utilize appropriate tools in conducting documentation so
that patient outcomes and professional practice can be enhanced.
Ways of Enhancing Proper Documentation

DOCUMENTING OF VITAL SIGNS BY NURSES
A number of studies suggested that there is a need for enhancing nursing
documentation. One of the ways of enhancing documentation as suggested by (Hayter &
Schaper, 2015) is through completing the records of the patients in an accurate manner.
Completing the records is important because at times it is difficult for nurses to communicate
face-to-face with patients. Therefore, proper documented information aids in improving
patient outcomes and safety. Additionally, nurses need to be conversant with the standards of
vital sign recordings and there is a need for educating them on the importance of following
those standards all the time. According to (Blair & Smith, 2012), the time taken for
documenting could be better managed by putting in place certain specifics such as ‘what
should be done’, ‘what has been done’, and the ‘outcome of that care’. That way,
documentation will be simplified and less time will be spent on documentation. Additionally,
documentation should be done throughout the shift so that last- minute rash can be avoided
(Blair & Smith, 2012). Standard 9 of the NSQHS requires health care facilities to put in place
systems that will recognize signs such as blood pressure and respiratory rate so that cardiac
arrest and other severe outcomes may be prevented (ACSQHC, 2016). In a study conducted
by (Stevenson et al., 2016), nurses described the documenting of vital signs using the EHRs
time-consuming and cumbersome. Therefore, it was suggested that writing by hand on paper
should be adopted because it takes less time and verbal communication should be adopted in
the retrieval of that information. A study by (Stevenson-Agren et al., 2017) suggested the
implementation of consistent routines as a way of curbing cases of poor documentation. The
health care facilities should also gather information and feedback regarding the experience of
individuals receiving care in their organizations (ACSQHC, 2014). Nurses should be
encouraged to show some levels of critical thinking in their documentation (Blair &Smith,
2012). The management of healthcare facilities should put in place a standardized format

DOCUMENTING OF VITAL SIGNS BY NURSES
needed in documenting the vital information of patients (Keenan et al., 2013). By doing that,
it will be possible to enjoy the benefits of new technology such as EHRs (Evans, 2016)
Conclusion
Appropriate documentation of vital signs in relation to determining deteriorating
patients remains a major concern in the healthcare industry. The recording systems such as
EHRs and observational charts are designed for the purposes of aiding appropriate
documentation by nurses and other medical staff. This literature highlighted that there are
varying views regarding the vital signs that should be documented. A number of barriers
facing appropriate documentation were recognized. However, for there to be appropriate
documentation in health care facilities, good governance should prevail (Houngbo et al.,
2017).

DOCUMENTING OF VITAL SIGNS BY NURSES
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