Nurses' Scraps: What Do They Tell Us?
Purpose
The purpose of this IRB-approved study was to describe the content of nurses' handwritten notes (scraps) used for patient care and handover report.
Background
Prominent organizations including the Joint Commission, World Health Organization, and the Agency for Healthcare Quality and Research also have published standards and recommendations on improving handover communication among healthcare providers. Standardizing the content of handover has been a common strategy to improve patient safety. In a qualitative study, nurses’ handwritten notes were found to be dynamic and played a significant yet undocumented role in the delivery of care Hardey (2000). Nurses used handwritten notes because of perceived inadequacies of organizational documentation systems. Much remains unknown about what nurses’ perceive as important information worth writing down.
Methods
This descriptive, cross-sectional study was conducted in a non-profit community hospital located in Southern California. A convenience sample of registered nurses with inpatient assignments was invited to voluntarily submit their written notes through an information letter. Submission of notes indicated consent to participate. These notes were not part of the patient’s medical record. Scraps and a demographic information sheet were collected in a sealed envelope over a 24-hour period. No participant identifying information was requested.
Results
A sample of 103 RNs submitted their “scraps” for analysis. The majority of participants were female (83%), BSN prepared (75%), with a mean age 38, and mean RN experience of 10 years. Participants wrote on both sides (56%), and customized with > 1 color/type of writing implement (41%), emphasis (87%), and symbols (100%).
Ninety-nine percent (99%) of report sheets included the patient’s name with 55% being handwritten. Fifty-one percent (51%) included account numbers and date of birth as second patient identifiers. Patient room numbers were handwritten on 70% of report sheets. From 78% to 92% of report sheets included some form of systems review (i.e. neuro, cardiac, pulmonary, etc.). A high percentage (≥ 90%) of report sheets included handwritten patient history, medications, vascular access, test results, tasks, and plan of care. Although some of the above items were commonly handwritten on report sheets, safety information, with the exception of allergies (88%) and vital signs (75%), was not. Isolation status (48%), fall risk (38%), hospital-acquired pressure ulcer risk (8%), other risks (20%), and vaccine status (12%) had low percentages of handwritten presence on report sheets.
Implications
Nurses’ scraps are context-specific, customizable, and contain emphasized information. Although nurses commonly handwrote patients’ background, assessment, and plan of care information, safety-related information was not present. These findings should inform additional studies on: 1) exploration of an electronic handover tool, nursing satisfaction, and handover time, and 2) examining the relationship between a standardized handover process and patient safety events at change of shift.