Compliance between registered nurses’ clinical judgment and documentation in homecare for older patients with COPD: A multiple case study

Registered nurses (RNs) play a crucial role in the clinical judgment (CJ) and documentation of health conditions healthcare patients diagnosed with chronic obstructive pulmonary disease (COPD). Using multiple case study approach, aim present was to explore describe RNs’ CJ homecare visits for older COPD as they appeared electronic patient records (EPRs) how well content corresponded what RNs explained verbally important report. Data were collected through observations 16 visits, interviews RNs, retrospective reviews EPRs. The is reported accordance COREQ. Quantitative qualitative analysis revealed that CJs represented only small extent mainly about procedures tasks performed did not correspond This knowledge contributes improvements ensure safety this research field.