ISSUES AND INNOVATIONS IN NURSING PRACTICE Discursive practices in the documentation of patient assessments Kate Irving BSc PhD RGN Lecturer, School of Nursing and Midwifery, University College Dublin, Dublin, Ireland Margaret Treacy MSc PhD RGN Professor of Nursing, School of Nursing and Midwifery, University College Dublin, Dublin, Ireland Annie Scott PhD RGN Professor of Nursing, School of Nursing, Dublin City University, Dublin, Ireland Abbey Hyde BSc MSc PhD RGN Senior Lecturer in Nursing, School of Nursing and Midwifery, University College Dublin, Dublin, Ireland Michelle Butler BSc MSc PhD RGN RM College Lecturer, School of Nursing and Midwifery, University College Dublin, Dublin, Ireland Padraig MacNeela PhD Lecturer in Psychology, Department of Psychology, National University of Ireland, Galway, Ireland Accepted for publication 12 May 2005 Correspondence: Kate Irving, School of Nursing and Midwifery, University College Dublin, Earlsfort Terrace, Dublin 2, Ireland. E-mail: kate.irving@ucd.ie IRVING K., TREACY M., SCOTT A., HYDE A., BUTLER M. & M IRVING K., TREACY M., SCOTT A., HYDE A., BUTLER M. & Mac acNEELA P. NEELA P. (2006) (2006) Journal of Advanced Nursing 53(2), 151–159 Discursive practices in the documentation of patient assessments Aim. This paper reports a study analysing the various functions of nurses’ docu- mentation of patient assessments. Background. Modes of documentation have received much attention in the nursing press since the integration of the nursing process and nursing models. Previous research has shown that current documentation practices do not consistently pro- mote effective communication and evaluation of patient care. A recent systematic review found no evidence that any particular system of documentation improved this situation. However, nurses’ documentation serves not only to communicate information to others, but also has a political function as a presentation of what is important and ethically ‘right’ to report. Method. A Foucauldian approach to discourse analysis was used to analyse 45 patient records. Findings. The findings indicate that nurses employ three discernible discursive practices in the documentation of patient assessments: medical, nursing and infor- mal. Each practice has an effect on the presentation of nursing in the documenta- tion. Because of the complex interplay between these practices, nurses present themselves as aligned with the medical profession, as distinct and professional, and as informal in their descriptions of non-biological information. The use of these practices appears to be motivated by the type of information being reporting. Conclusion. Existing literature highlights the functional aspects of nursing docu- mentation. In contrast, this paper explores the way in which nurses, through their documentation, constitute themselves and the nursing profession. In this way, Ó 2006 Blackwell Publishing Ltd 151