Documentation of diabetes care in home nursing service in a Swedish municipality: a cross-sectional study on nurses' documentation

Scand J Caring Sci; 2011; 25; 220–226 Documentation of diabetes care in home nursing service in a Swedish municipality: a cross‐sectional study on nurses’ documentation Objectives: To assess what was documented by Registered Nurses regarding diabetes care in a Swedish municipality’s home nursing service; to what extent diabetes‐related nursing actions were planned for, performed and evaluated according to the goals of metabolic control, treatment and prevention of complications. Design: Cross‐sectional study. Subjects: Registered Nurses’ documentation of patients with diabetes mellitus (n = 172). Main outcome measurers: Number of recorded different nursing actions planned, performed and evaluated. Result: The overall standard of records was insufficient. Evaluation of blood glucose levels and metabolic control was documented in 61% of the records; weight was documented in 4% of the records. Blood pressure was recorded in 10%. Ongoing foot ulcers were documented in 21%. Patient education or actions to prevent foot ulcers was not recorded. Tablet and insulin administration were well recorded. The nursing process was not followed. Study limitation: Updated medicine lists were missing in many files, this might have resulted in an underestimation of the number of included records. Conclusion: The Registered Nurses are responsible for a vulnerable patient group suffering from multi‐organ disease unable to maintain their own diabetes self‐care. Insufficient documentation may lead to impaired quality of care. We suggest that improved documentation routines include a structure of planning, performing and evaluation of metabolic control (blood glucose measurements, Hba1c, weight and nutrition status), complications (regular blood pressure measurements, protective foot care) and education of health care assistants in assisted diabetes self‐care.