Nursing care plans within electronic medical record systems have the potential to support nurses in planning and prioritizing patient care; however, there is a gap in the literature related to nurses' experiences of how this may occur. The aims of this mixed-methods study included exploring nurses' documentation adherence, identifying barriers and enablers to care plans documentation, and making recommendations to enhance nurses' use of care plans within electronic medical records. An audit of 142 patients revealed the majority had at least one care plan initiated in the electronic medical record (n = 120, 84.5%), 63 patients had a care plan initiated within 24 hours of admission (n = 63, 44.4%), and only three had care plans documented against in the previous 48 hours (2.11%). Data from six focus groups were developed into two themes (each with two subthemes): “Mind the Gap” and “Making It Work for Us.” Barriers and enablers were identified and mapped to 10 of the 14 domains of the Theoretical Domains Framework. There was large variability in nurses' knowledge and understanding related to the need for care plans documentation. Assessment of usability and/or redesign of care plans within electronic medical records must align to nursing workflows to support clinical care delivery.
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