![]() ![]() Preventable harms in hospital are defined as presence of an identifiable, modifiable cause of harm (Nabhan et al., 2012). Nurses value text boxes which enable them to document the clinical nurse decision-making they conduct in the process of individualising care.Nurses and patients experience a lack of integration with multidisciplinary teams, which is reinforced by documentation structures.Nurses prioritise direct patient care over documentation requirements, but efficient documentation structures are valued by nurses when they can quickly inform their patient focused care.What does this paper contribute to the wider global clinical community? The integration of effective MDT involvement in clinical documentation was problematic and resulted in unmet supportive care from the patient's perspective. ConclusionsĮfficient and streamlined documentation systems should herald feedback from nurses to address their clinical workflow needs and can support, and capture, their decision-making that enables partnership with patients to improve the individualisation of care provision. ![]() (3) ‘Experience of care’ satisfaction of person-centred care communication in the MDT was important, but sometimes insufficient patients had variable involvement in their daily care plan and inadequate integration of care between MDT team which negatively impacted patients. (2) ‘What does not work well in practice’: obtaining the patient's signature on daily care plans multidisciplinary (MDT) involvement duplication of paperwork and person-centred goals are not well-captured in care plan documentation. Three main themes emerged: (1) ‘What works well in practice’ included: efficiency in the structure of the documentation the Introduction, Situation, Background Assessment, Recommendation (ISBAR) framework and prompting for clinical decision-making were valued by nurses and direct patient care is always prioritised. The audio recording was transcribed, and an inductive thematic analysis was used to provide insight from multiple perspectives. Semi-structured interviews and focus groups were conducted at two time points. A sample of 111 participants (12 patients, 4 family members/carers, 94 nurses and 1 allied health professional) from a range of wards/clinical locations. Metropolitan tertiary hospital and rehabilitation hospital servicing a population of 550,000. DesignĪ qualitative descriptive study reported according to COREQ. However, little is known about how nurses use multidimensional assessment documentation in clinical practice to address preventable harms and optimise person-centred care. There is increasing emphasis on multidimensional risk assessments during hospital admission. To explore organisation-wide experiences of person-centred care and risk assessment practices using existing healthcare organisation documentation. ![]()
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