LAUSR

Abstract Purpose Nurses are on the forefront of delivering care to patients hospitalized with COVID‐19. Nurses’ impact on patient care can be discerned through assessment and documentation strategies, including structured and unstructured narratives, clinical pathways, flowsheets, and problem‐based approaches. To date, there are no published reports regarding nursing assessment and documentation during the COVID‐19 pandemic using an assessment framework to capture clinical decision making, nursing diagnoses, and key social determinant of health (SDoH) data. Hence, the purpose of this investigation was to conduct an exploratory nursing documentation audit of patients hospitalized with COVID‐19 during the first surge to identify types and frequency of nurse‐sensitive indicators, including SDoH. Method This pilot study utilized a retrospective chart review design at a single academic medical center, utilizing Gordon's Eleven Functional Health Patterns (FHP) framework to extract clinical, social, and nursing assessment data for patients hospitalized with COVID‐19. Descriptive statistics were computed for continuous variables and counts/percentages for categorical variables. Findings Data from 94 patient records were analyzed. Most patients were male (59.6%), with a mean age of 58 years. Nearly 15% of patients were Black and 12.8% were Hispanic, most residing in four geographic areas. Nine of the 11 FHPs were reflected in nurse‐sensitive indicators documented in the electronic health record. SDoH data were inconsistently documented, including race, education, history of neglect/abuse, and occupation. Conclusion The FHP framework captured many nurse‐sensitive indicators during the first COVID‐19 surge, although screening for and documenting SDoH data were limited. Implications for nursing practice Findings can influence the development of nursing assessment and documentation during crisis care delivery that are inclusive of distinct sociodemographic factors, in addition to clinical factors, to provide comprehensive, culturally sensitive care. Such documentation will enhance the use of nursing knowledge guided by a nursing framework to make visible the essential contributions of nurses to healthcare delivery.