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 = 12O) 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.