PURPOSE.To describe the main problems, needs, risks, and nursing diagnoses and to examine the descriptions of some common and serious patient problems in nursing home records.
METHODS.A retrospective audit of a stratified, random sample (N = 120) of patient records from eight nursing homes in six Swedish municipalities.
FINDINGS.Results showed major deficiencies in nursing documentation in the patient records. Only one record contained a comprehensive description of one patient problem that corresponded to the requirements of Swedish laws and regulations. No record was found that contained a systematic and comprehensive assessment of any of the selected problems based on established criteria or the use of an assessment instrument.
CONCLUSIONS.Nursing documentation in patient records does not reflect the use of systematic assessment and research-based instruments for determining patient care needs. Nurses need skills in assessment in the care of the elderly to be able to set priorities in care and deliver adequate care.
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