Quality of nursing documentation and approaches to its evaluation ...

JAN
JOURNAL OF ADVANCED NURSING
REVIEW PAPER
Quality of nursing documentation and approaches to its evaluation:
a mixed-method systematic review
Ning Wang, David Hailey & Ping Yu
Accepted for publication 22 January 2011
Correspondence to P. Yu:
e-mail: ping@uow.edu.au
Ning Wang RN
PhD Candidate
Health Informatics Research Lab, School of
Information and Technology, Faculty of
Informatics, University of Wollongong,
New South Wales, Australia
David Hailey PhD
Research Fellow
Health Informatics Research Lab, School of
Information and Technology, Faculty of
Informatics, University of Wollongong,
New South Wales, Australia
Ping Yu PhD
Senior Lecturer, Research Director
Health Informatics Research Lab, School of
Information and Technology, Faculty of
Informatics, University of Wollongong,
New South Wales, Australia
WANG N., HAILEY D. & YU P. (2011)
Quality of nursing documentation and
approaches to its evaluation: a mixed-method systematic review. Journal of
Advanced Nursing 00(0), 000–000. doi: 10.1111/j.1365-2648.2011.05634.x
Abstract
Aims. This paper reports a review that identified and synthesized nursing
documentation audit studies, with a focus on exploring audit approaches, identifying
audit instruments and describing the quality status of nursing documentation.
Introduction. Quality nursing documentation promotes effective communication
between caregivers, which facilitates continuity and individuality of care. The
quality of nursing documentation has been measured by using various audit
instruments, which reflected variations in the perception of documentation
quality among researchers across countries and settings.
Data sources. Searches were made of seven electronic databases. The keywords
‘nursing documentation’, ‘audit’, ‘evaluation’, ‘quality’, both singly and in combination,
were used to identify articles published in English between 2000 and
2010.
Review methods. A mixed-method systematic review of quantitative and qualitative
studies concerning nursing documentation audit and reports of audit instrument
development was undertaken. Relevant data were extracted and a narrative
synthesis was conducted.
Results. Seventy-seven publications were included. Audit approaches focused on
three natural dimensions of nursing documentation: structure or format, process
and content. Numerous audit instruments were identified and their psychometric
properties were described. Flaws of nursing documentation were identified and the
effects of study interventions on its quality.
Conclusion. Research should pay more attention to the accuracy of nursing documentation,
factors leading to variation in practice and flaws in documentation
quality and the effects of these on nursing practice and patient outcomes, and the
evaluation of quality measurement.
Keywords: audit, evaluation approaches, instruments, nursing documentation,
quality, quality criteria, systematic review
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N. Wang et al.
Introduction
In modern healthcare organizations, the quality and coordination
of care depend on the communication between
different caregivers about their patients. Documentation is a
communication tool for exchange of information stored in
records between nurses and other caregivers (Urquhart et al.
2009). Quality nursing documentation promotes structured,
consistent and effective communication between caregivers
and facilitates continuity and individuality of care and
safety of patients (Björvell et al. 2000, Voutilainen et al.
2004).
Nursing documentation is defined as the record of
nursing care that is planned and given to individual
patients and clients by qualified nurses or by other
caregivers under the direction of a qualified nurse (Urquhart
et al. 2009). It attempts to show what happens in the
nursing process and what decision-making is based on by
presenting information about admission, nursing diagnoses,
interventions, and the evaluation of progress and outcome
(Nilsson & Willman 2000, Karkkainen & Eriksson 2003).
In addition, nursing documentation can be used for other
purposes such as quality assurance, legal purposes, health
planning, allocation of resources and nursing development
and research. For achieving these purposes, nursing
documentation needs to hold valid and reliable information
and comply with established standards (Idvall &
Ehrenberg 2002, Karkkainen & Eriksson 2003, Urquhart
et al. 2009).
Nursing has been concerned with patient data since the
early days of Nightingale (Gogler et al. 2008). It was
advanced with the introduction of the nursing process into
the clinical setting (Oroviogoicoechea et al. 2008). The
nursing process is a structured problem-solving approach to
nursing practice and education and was first explained by
Yura and Walsh in 1967. It originally comprised of four
stages: assessment, planning, implementation and evaluation
of care and lately included nursing problem or diagnosis
(Björvell et al. 2000). The nursing process model has been
widely used as a theoretical basis for nursing practice and
documentation.
Over the last few decades, more efforts have been made to
advance nursing documentation to increase its usability. One
of these initiatives was the development and use of researchbased
standardized nursing terminologies such as the International
Classification of Nursing Practice (ICNP) and the
International Nursing Diagnoses Classification (NANDA
International). Standardized nursing languages provide common
definitions of nursing concepts and allow for theorybased
and comparable nursing data to emerge. Therefore,
they promote shared understanding and continuity of care
and make it possible to use records for research and
management purposes (Müller-Staub et al. 2007, Thoroddsen
& Ehnfors 2007).
The introduction of electronic documentation systems
into care practice has led to the transformation of nursing
record-keeping. Electronic documentation systems can
improve health professionals access to more complete,
accurate, legible and up-to-date patient data (Larrabee
et al. 2001, Oroviogoicoechea et al. 2008), although their
effects on patient outcomes are inconclusive (Urquhart
et al. 2009). With the widespread use of information
technologies in nursing practice, standardized nursing language
becomes essential because a uniform and controlled
vocabulary enables electronic documentation systems to
aggregate data (Ehrenberg et al. 2001, Müller-Staub et al.
2008b).
Despite the wide recognition of the importance of quality
nursing documentation and efforts made to enhance it,
there are inconsistencies in the definition of good nursing
documentation because of variations in nursing documentation
practice based on different local requirements,
documentation systems and terminologies across countries
and settings. In research settings, the quality of nursing
documentation has been assessed by various auditing
instruments with different criteria reflecting how quality
was perceived by the researchers. There have been several
recent reviews of nursing documentation. A systematic
review conducted by Saranto and Kinnunen (2009) covered
41 studies on evaluating nursing documentation and
focused on research designs and methods, which were not
limited to record audit. The review provided insights into
several audit instruments and issues relating to documentation
quality, but quality measures were not fully
addressed. Other reviews on nursing documentation have
had different focuses (Müller-Staub et al. 2006, Oroviogoicoechea
et al. 2008, Urquhart et al. 2009, Jefferies et al.
2010). None of them has concentrated on overall measurement
standards and outcomes of nursing documentation
itself, although segmental relevant information was found.
This review attempts to provide such information to fill in
the gap.
The review
Aim
To identify and synthesize nursing documentation audit
studies. The objectives include: exploring nursing documentation
auditing approaches, identifying audit instruments and
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Quality of nursing documentation and audit
their measurement criteria and describing issues with nursing
documentation identified by auditing.
1763 citations identified from
electronic search, and screened
Design
219 citations identified from 4
reviews, and screened
1797 citations excluded
A mixed-method systematic literature review was conducted,
following the guidelines of the Centre for Reviews and
Dissemination (2008).
Search methods
A search for relevant publications was mainly undertaken in
November and December 2009 on seven electronic databases
(CINAHL, the Cochrane Library, Health Reference Center,
ProQuest – Nursing, Wiley InterScience, Medline 1996 – and
Nursing Resource Centre). The search terms ‘nursing documentation’,
‘nursing records’, ‘audit’, ‘evaluation’ and ‘quality’,
both singly and in combination, were used to identify
articles. The search was restricted to articles published in
English from 2000 to 2009. However, a new search for
update evidence was carried out on August 2010. The
following criteria were used in selecting papers:
Inclusion criteria
• Publications of nursing documentation audit studies.
• Reports on the development or testing of nursing
documentation audit instruments.
• Any type of nursing documentation system, either paperbased,
electronic, terminologically standardized, preformatted
or structured.
• Any component of nursing documentation such as nursing
assessment forms, care plan and progress notes.
• Audit studies conducted in any setting: hospital, aged care
facility and community etc.
Exclusion criteria
• Papers not dealing with nursing documentation.
• Review and contextual papers, editorials, letters and case
studies.
• Publications about nursing documentation requirements or
guidelines.
• Papers on issues of nursing documentation other than its
quality, e.g. development of documentation systems,
factors affecting the quality of documentation and how to
complete nursing documentation.
• Papers on evaluating nursing documentation through
surveys and interviews.
• Papers concerning documentation of health professions
other than nursing.
• Duplicated papers on the same study.
Search outcome
The titles and abstracts from the primary search were
manually screened by the first author. Reference lists from
good quality literature review were also scrutinized for
relevant articles. Uncertain papers were checked by the third
author to determine their relevance. Seventy-seven papers
were finally included in the review following a screening
process as shown in Figure 1.
Quality appraisal
As determining the methodological adequacy of studies was
not essential for the purpose of the review, a formal quality
assessment of review studies was not conducted; however,
some consideration was given to prioritizing studies for
analysis according to the level of detail given on the audit
instruments, and the relevancy and significance of auditing
approaches to nursing practice.
Data abstraction
Extracted data were placed in an Endnote file. These data
included study aim, design, study intervention, country of
origin, setting, sample size, documentation audit instrument,
quality criteria, source of criteria, validation of
instrument, approach of evaluation and key findings of
the studies.
Synthesis
185 potentially relevant
publications retrieved for
scrutiny
77 publications included
Figure 1 Publication search process.
108 publications excluded
Given the purpose of the review, meta-analysis was neither
appropriate nor feasible for data synthesis. The papers were
grouped by the type of studies. A narrative synthesis of
extracted data was undertaken using tables with emerging
thematic headings.
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N. Wang et al.
Results
Characteristics of studies
The 77 eligible papers consisted of different types of studies
carried out in various healthcare settings across 15 countries.
The sample sizes ranged from 15 to 13,776 presented as the
number of records, number of patients, number of documentation
items and number of patient visits. Nursing documentation
was audited for different purposes. These were either
explicitly or indirectly stated by the authors primarily to
address the quality of description of care or the quality of
described care. Summarized information on the studies
is shown in Table 1. Detailed information is displayed in
Tables S1–S3.
Approaches to nursing documentation audit
Nursing documentation was assessed by quantitative and
qualitative content analysis methods, mostly with one or
more formally defined instruments. Commonly, each nursing
record was graded quantitatively using yes/no tick box or 3,
4, 5 and/or 6 point Likert scales. A few studies, however, used
qualitative content analysis methods such as critical discourse
analysis (Karlsen 2007), constant comparative analysis
(Laitinen et al. 2010) and a case-by-case approach to draw
out themes from nursing records (Hegarty et al. 2005).
Table 1 Summary of included publications (n = 77)
Study type
(number of studies)
Countries of
origin
(number of studies)
Study setting
(number of studies)
Descriptive studies (45)
Analytic studies (25): pre-post
intervention test (12),
quasi-experimental studies (7),
randomized controlled trials (3),
cluster-randomized trial (1),
prospective (1), stratified and
randomized intervention study (1),
prospective cohort study (1)
Instrument development and
testing reports (7)
Sweden (27), USA (11), Australia (8),
Finland (8), Switzerland (4), Norway
(4), UK (3), Germany (2), Canada (2),
Iceland (2), Italy (1), Netherlands (2),
Ireland (1), Rwanda (1), Denmark (1)
Auditing studies: Hospital (51), long-term
care (7), primary care (6), community
care (4), school health centre (1),
mixture of hospital and nursing home (1)
Reports of instrument development and
testing (7): six instruments were reported
in the seven papers and were developed
based on hospital settings
Different auditing approaches were identified in the study
instruments. These approaches were classified into three
thematic categories, which reflected natural dimensions of
nursing documentation: structure and format, process and
content. In 47 studies, a single approach was used, while a
mixture of approaches was applied in the other. Detailed
quality criteria are presented in Table 2. Different types of
auditing approaches are displayed in Table 3.
Approach concerning documentation format and
structure
The approach concerning the format or structure dealt with
constructiveormaterialfeaturesratherthanthemessageofdata.
Itfocusedondata’sphysicalpresentationssuchasthequantityof
records, completeness, legibility, readability, redundancy and
the use of abbreviations. Twenty studies applied this approach.
Approach concerning documentation process
The process approach focused on procedural issues of
capturing patients’ data such as signature, designation, date,
timeliness, regularity of documentation and its accuracy to
reality. The accuracy of documentation was measured by the
concordance between different notes, or between documentation
content and the results of patient assessment
(Gunningberg & Ehrenberg 2004, Voyer et al. 2008), nurses’
self reports (Lamond 2000), interviews with nurses and
patients (Ekman & Ehrenberg 2002, Wong 2009) and
observation of nurse performance (Marinis et al. 2010).
The process approach was used in 23 studies.
Approach concerning nursing documentation content
The content approach focused on the meaning of data about
care process. This approach was adopted in nearly all of the
studies included, where the content of documentation was
reviewed in general or specifically in relation to a range of
focused care issues. When nursing care or nurses’ knowledge
about care was concerned, the authors made judgments based
on an underlying assumption that the information documented
in the nursing records was complete and accurately reflecting
reality. Two quality aspects of documentation content were
assessed in this approach: what documentation has recorded
and how good it is.
What has documentation recorded?
This approach referred to the comprehensiveness of documentation
content. It concerned the presence of data about a
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Quality of nursing documentation and audit
Table 2 Quality criteria of nursing documentation
Category
Quality criteria of documentation structure
and format
Quality criteria of documentation process
Quality criteria of documentation content
• Comprehensiveness of description
of care (or care)
• Appropriateness of description
of care (or care)
s Nursing assessment
s Nursing problem/diagnosis
s Goal
s Intervention
s Evaluation
s General
Quality criteria
Completeness, quantity, legibility, appearance, plausibility, patient identification,
abbreviations, correction of error, linguistic correctness (objective or factual language
and scientific terms), chronological report of events, the colour of the ink, blank spaces
and gaps within the text, documentation in a correct section, the phrases of recording,
succinct and clear language, avoidance of use of jargon or technical terms
Signature, date, timeliness, chronological report of events, designation, regularity,
accuracy in comparison with reality and accessibility
Presence of specific types of documentation (e.g., nursing history and discharge note),
presence of specific variables (e.g., patient’s background information, cause of
admission, address of discharging unit), comprehensiveness of five phases of nursing
process, scope of care (e.g., FHP), presence of information about specific care topics
(e.g., teaching and learning of the patient, emotional and physical support of the
patient or family, patient preference)
Presence of specific assessment variables in relation to the problem according to
guideline (e.g. grade, size and location and risk assessment for pressure ulcer), use of
specific keywords defined in the system in relation to the problem concerned
(e.g., pedagogically related assessment keywords defined in the VIPS model).
Adequacy or accuracy of problem statement in accordance with NANDA standardised
terminologies (e.g., PES format), the relevance within PES
Being clear rather than abstract and vague
Presence of particular types of intervention in relation to the nursing problem according
to guidelines (e.g., fluid intake, turning schedule for pressure ulcer), use of specific
keywords defined in the system in relation to the nursing problem (e.g., intervention
keyword of health promotion for school nursing programmed in the computer system),
presence of NIC interventions
Presence of NOC (nursing outcome classification) outcomes
Internal relationship with five steps of nursing process
care process at a general level, without considering its logical
connection to a particular care issue or the patient’s condition.
Issues measured included whether documentation contained
certain types of data such as nursing history, nursing status
(Björvell et al. 2002, Gjevjon & Hellesø 2010), baseline data
and discharge summary (Mbabazi & Cassimjee’s 2006);
whether documented nursing care was sufficient to the scope
of care needs defined by the study, such as the Health-Related
Quality of Life (HRQOL) model’s seven dimensions (Davis
et al. 2000); and most commonly, whether information about
the five steps of nursing process was adequately documented
(Ehrenberg & Birgersson 2003, Björvell et al. 2002, Mahler
et al. 2007, Thoroddsen et al. 2010, Hayrinen et al. 2010).
How good is nursing documentation content?
This approach addressed the appropriateness of nursing
documentation or documented care at a level specific to a
particular clinical care issue such as pressure ulcers
(Gunningberg et al. 2009) or postoperative pain (Idvall &
Ehrenberg 2002). Documentation content about each step of
the nursing process was measured through seeking data
specifically related to the concerned clinical issue: could be
particular keywords preformatted in a standardized documentation
system (Bergh et al. 2007), variables of clinical
policies or guidelines (Considine & Potter 2006, Junttila
et al. 2010, Gartlan et al. 2010) or standardized terminologies
(Lunney 2006, Hayrinen et al. 2010). The structure and
format of the diagnostic statement (PES format: problem,
aetiologies and signs and symptoms) and the internal linkage
between the five phases of the nursing process (Florin et al.
2005, Müller-Staub et al. 2009, Paans et al. 2010b) were also
covered by this approach.
Nursing documentation audit instruments
The majority of papers described the development or use of
nursing documentation auditing instruments, which adopted
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N. Wang et al.
Table 3 Nursing documentation audit instruments and measurement details
Reference Instrument Audit
approaches
Measurement details
Bergh et al. (2007)
Ehrenberg &
Birgersson (2003)
Idvall & Ehrenberg
(2002)
Ehrenberg et al.
(2004)
Gunningberg &
Ehrenberg (2004)
Gunningberg
(2004)
Gunningberg et al.
(2009)
Gjevjon & Hellesø
(2010)
Gunningberg et al.
(2000)
Gunningberg et al.
(2001)
Baath et al.
(2007)
Fribeg et al.
(2006)
Björvell et al.
(2000)
Björvell et al.
(2002)
Tornvall et al.
(2004)
Tornvall et al.
(2007)
ESCI*
Quantitative and
qualitative keywords
analysis
ESCI*
Nominal scale
ESCI*
Tentative model
NANDA*
characteristics
of acute
pain
ESCI*
Record audit
ESCI*
EPUAP *
ESCI*
Record
audit protocol
ESCI*
EPUAP*
Level one VIPS*
categories
Modified ESCI*
Audit protocol
ESCI*
Content
Using five-point scales to measure the comprehensiveness of
documentation of five steps of nursing process
Quantity of documentation of pedagogically related keyword;
presentation in thematic form
Content See Bergh et al. (2007)
Documentation of specific signs and symptoms related to leg ulcer
and their accordance with guidelines
Content See Bergh et al. (2007)
Documentation of indicators/categories related to how to conduct
postoperative pain management
Documentation of pain characteristics
Content See Bergh et al. (2007)
Documentation of specific aspects of nursing assessment and
nursing interventions for patients with CHF
Content
and process
See Bergh et al. (2007)
Documentation of patient’s background data, pressure ulcer grade,
size and location, risk assessment and preventive care
Comparing results of documentation audit with results of patient
assessment
Content See Bergh et al. (2007)
Documentation of risk factors, risk assessment, prevention and
treatment of pressure ulcer
Content See Bergh et al. (2007)
Documentation of patient background data, pressure ulcer grade,
size and location, risk assessment and nursing interventions
Content
Presence of documentation according to level one categories of
VIPS* model such as nursing history, nursing status and dis
charge notes
An additional scale of 0 to the original five-point scales of ESCI*
instrument concerning the five steps of nursing process
Content
Documentation of strategies for prevention and treatment of
pressure ulcers
See Bergh et al. (2007)
Audit protocol Content See Gunningberg et al. (2000)
Audit protocol
ESCI*
Protocol
ESCI*
Cat-ch-Ing
instrument
Cat-ch-Ing
Instrument
Cat-ch-Ing
instrument
Cat-ch-Ing
audit instrument
Content See Gunningberg et al. (2000)
See Bergh et al. (2007)
Content
Documentation of patient teaching; patients’ need for knowledge
and nurses’ teaching interventions
See Bergh et al. (2007)
Structure, process Using four-point scales or yes/no to measure the quantity and
and content
quality of documentation of nursing process; the use of VIPS
keywords; the presence of date, signatures and clarification of
signatures; linguistic correctness and legibility
Structure, process See Björvell et al. (2000)
and content
Structure, process See Björvell et al. (2000)
and content
Structure, process See Björvell et al. (2000)
and content
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Table 3 (Continued)
Reference Instrument Audit
approaches
Measurement details
Aling (2006)
Tornvall et al.
(2009)
Darmer et al.
(2006)
Nilsson & Willman
(2000)
Rykkje
(2009)
Hayrinen et al.
(2010)
Florin et al. (2005)
Larson et al.
(2004)
Müller-Staub et al.
(2009)
Müller-Staub et al.
(2008a)
Müller-Staub et al.
(2007)
Müller-Staub et al.
(2008b)
Altken et al.
(2006)
Ammenwerth et al.
(2001)
Cadd et al.
(2000)
Considine & Potter
(2006)
Davis et al.
(2000)
Cat-ch-Ing
instrument
(modified)
Cat-ch-Ing
instrument (part)
Record audit for
clinical issues
Cat-ch-Ing
instrument
(modified)
Cat-ch-ing
instrument (part)
NoGA instrument*
Modified Cat-ch-ing
instrument
Modified Cat-ch-Ing
instrument
Quantity of nursing
documentation
Cat-ch-Ing instrument
(part)
QOD instrument*
The Cat-ch-Ing EPI
instrument
Structure and
content
Content
Structure, process
and content
Structure, process
and content
Structure, process
and content
Structure, process
and content
Content
Process and
content
Questions related to discharge note, signing and using VIPS
keywords were removed. Language, grammar and abbreviations
were concerned. Maximum of 57 points instead of 80
Audit of date, signatures; clarification of signatures and legibility
were excluded
Documentation of important clinical nursing issues with regard to
aspects in relation to leg ulcer such as health history, knowledge/
development, breathing/circulation, nutrition, wound status, rel
evant interventions and evaluation
The item of nursing discharge note in the Cat-ch-Ing instrument
was excluded; the measurement of nursing diagnosis item was
simplified
The first part of the instrument (preliminary?)
Item concerning clarification of signature was excluded. Details
not fully clear
Quantity of the five steps of nursing process
Adding two items related to the quantity and quality of nursing
transfer note and nursing discharge summary
See Björvell et al. (2000). Adding measure of the use of nursing
classifications (FiCNI and FiCND) and the relationships between
classification
Frequency of the nursing diagnoses, aims for care, nursing
interventions and nursing outcomes
Only the quantity and quality variables of nursing diagnosis were
used
Structure and format of diagnostic statement and the relevance in
PES
Using four-point scale to measure the quantity and quality of
documentation in discharge note concerning given care,
continued nursing needs, planned care, and general data
including signature and data
Q-DIO instrument* Content Using 3- and 5-point scales to measure the quality of documented
nursing diagnosis (as process and product), interventions, out
comes and their internal relationships
Q-DIO instrument* Content See Müller-Staub et al. (2009)
Q-DIO instrument* Content See Müller-Staub et al. (2009)
Q-DIO instrument
(part) *
Content
See Müller-Staub et al. (2009). The category nursing diagnosis as
process was excluded
3-part medication Content
Documentation of patient’s demographic information,
audit
medications and detailed data about nurses’ medication
instrument
management including assessment, planning care, medication
administration and evaluation of outcomes
Checklist
Structure and
Objective quality measurements (e.g. number of stated nursing
content
aims, completeness) and subjective quality measurements (e.g.
legibility, plausibility, overall quality judgment)
Proforma Content Documentation of admission assessment about patients’ home
bowel care management and preferences for care
Standardized
Content
Documentation of nineteen parameters of initial nursing
audit tool
assessment, historical variables and primary survey assessment
HRQOL* model Content Documentation of health status in accordance with seven
dimensions of the model
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N. Wang et al.
Table 3 (Continued)
Reference Instrument Audit
approaches
Measurement details
Dalton et al.
(2001)
Daly et al.
(2002)
Delaney et al.
(2000)
Dochterman et al.
(2005)
Ehrenberg & Ehnfors
(2001)
Eid & Bucknall
(2008)
Ehrenberg et al.
(2001)
Ekman &
Ehrenberg
(2002)
Gartlan et al.
(2010)
Gebru et al.
(2007)
Gregory et al.
(2008)
Gunhardsson et al.
(2007)
Audit instrument Content Documentation of items about pain assessment and management:
e.g. pain history, type and intensity, and follow up evaluation
Standardized
Structure
Quantity of nursing diagnosis and nursing interventions
instruments
An auditing tool Content Presence of data in accordance with items listed in the instrument
including NANDA diagnostic label, defining characteristics and
related factors of impaired physical mobility
NIC* (250/514) Content
Amount and patterns of NIC* interventions used for patients with
interventions
heart failure, hip fracture procedure and risk of falls
Record audit
Content and
Documentation with regard to the topics such as patient’s
protocol
process
problems relating to urinary incontinence, mental condition,
mobility, nutritional intake, skin condition and fluid intake
Concordance between audit results and the results of interviews
with residents and nurses concerning the same topics
PDAT* Content Patient demographic data, diagnosis, co-morbidities, type of
operation, information on pain assessment, management and
education
Approaches
derived from a
literature review
FIS*
A paper-based
audit tool
Qualitative content
analysis
Leininger’s Sunrise
Model
Documentation audit
tool
Qualitative and
quantitative
content analysis
Structure, process
and content
Process and
content
Content
Content
Content (structure
and process?)
Content
Formal structure approach (adherence to law and regulations),
process comprehensiveness [ESCI-see Bergh et al. (2007)], and
knowledge based approaches
Nominal scale to measure the frequency of 10 characteristics of
fatigue from NANDA*; comparison of audit results with the
results of interviews with patients
Focusing on wound documentation about assessment of clinical
history in relation to the wound and documentation of the
physical characteristics of a wound
Identification and coding of entries about patient cultural
background information; quantity of documented data according
to the categories of Sunrise Model
Compliance to documentation policy (no detailed information
reported), documentation of baseline assessment, episodes of
care, patient’s overall status, ongoing management plan;
objective assessment
Documentation of the VIPS keywords; presentation in appropriate
category in the theoretical framework of palliative care
Hare et al. (2008) Tick–box list Content Documentation of patient’s demographic information, cognitive
and behavioural changes, pre–existing, confirmed diagnosis of
dementia, confusion on admission, cause of confusion and
behavioural descriptors and nurses’ use of formal cognitive
assessment tools
Hansebo & Kihlgren
(2004)
Hayrinen & Saranto
(2009)
Hegarty et al. (2005)
Quantitative content
analyses
RAPs*
Intervention guidelines
Narrative content
analysis
Quantitative and
qualitative data
analysis
Structure and
content
Content
Content
Amount of care plan, daily notes and steps of nursing process, the
nature of interventions, the language used for documentation,
clarity of documentation, amount of documented triggered RAPs
and accordance of documented items in care plans to triggered
RAPs, etc
Quantity, format and accuracy of the documentation of nursing
diagnoses, nursing care aims, nursing interventions (planned/
performed) and nursing outcomes
Documentation of comprehensive nursing assessment, appropriate
nursing interventions and the outcomes of the interventions for
patients with end-of-life care; case-by-case approach to draw out
themes within the categories
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Table 3 (Continued)
Reference Instrument Audit
approaches
Measurement details
Helleso (2006)
Irving et al. (2006)
Junttila et al. (2010)
TWEEAM instrument*
Language functions of
Svennevig’s typologies
A Focucauldian
approach to discourse
analysis
List of nursing
diagnoses in the
PNDS
Structure and
content
Structure and
content
Content
Using a three-point scale to measure the completeness of items in
the discharge notes in accordance with six sections of the
instrument; the completeness of 12 keywords in the section of
Patient’s Current Status; data of discharge notes
Three language functions (expression, interpersonal and
referential)
Qualitative analysis; medical, nursing and informal; types,
content/message, and terminologies of documentation of
assessment, the tone of nurses’ expression and its implications,
nursing models underlying nursing documentation
Prevalence of nursing diagnoses listed in the PNDS by
perioperative phases
Junttila et al. (2000) Categorization table Content Documentation of planning, implementation and evaluation of
perioperative care and additional information with subcategories
such as physical and psychological safety and asepsis in
perioperative care
Karlsen (2007)
Karkkainen &
Eriksson (2003)
Karkkainen &
Eriksson (2005)
Lemay et al.
(2004)
Lamond (2000)
Critical discourse
analysis
Lukander’s Nursing
Audit instrument
Structure and
content
Content
The nurses’ language expression in assessing patient’s needs,
formulating goals and making a care plan, diagnostic systems and
documentation parlance
Four-point scale to measure the documentation according to
categories such as patient analysis and its recording, patient
teaching and learning, evaluation of the nursing care, prevention
of complications and errors
Lukander’s Nursing
Audit instrument
Content See Karkkainen & Eriksson (2003)
Abstraction tool Content Documentation of BMI calculation, an obesity diagnosis, and
inclusion of heights and current weights
Coding scheme of
MSA*
Content and
process
Documentation of comprehensiveness variables concerning patient
assessment; concordance of information between the patient
notes and the nurse shift report
Lunney (2006) NNN* Content Documentation of NANDA diagnoses, diagnoses relating to health
Lagerin et al.
(2007)
Laitinen et al.
(2010)
Larrabee et al.
(2001)
Mahler et al.
(2007)
Marinis et al.
(2010)
Mbabazi &
Cassimjee
(2006)
promotion, NIC* interventions and NOC* outcomes
Checklist Content Documentation of VIPS keywords covering 10 key areas of leg
ulcer care and treatment
Strauss and Corbin’s Content
Concepts obtained through a series of qualitative data analysis
paradigm model
steps were organized into four components of the paradigm
model: conditions, interaction, emotions and consequences
NCPDCI*
Quantitative and
qualitative checklist
Structure and
content
Structure, process
and content
Documentation of nurse assessments of patient outcomes
(NASSESS), achievement of patient outcomes (NGOAL), nursing
interventions done (NQUAL) and routine assessment (e.g. vital
signs)
Quantity and quality aspects of description of the course of care,
participation of the patient in care planning, formal aspects of
data entry, plausibility and value-free documentation
Checklists Content and process Consistency between recorded and observed nursing assessment
activities and interventions
3-section quality Structure, process Documentation of baseline data, diagnosis, treatments,
measurement
and content
evaluations and discharge summary; regularity of vital sign
checklist
measurement, use of scientific terms and chronological report of
events
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N. Wang et al.
Table 3 (Continued)
Reference Instrument Audit
approaches
Measurement details
Moult et al.
(2004)
Paans et al.
(2010a)
Paans et al.
(2010b)
Souder &
O’Sullivan
(2000)
Thoroddsen &
Ehnfors
(2007)
Thoroddsen et al.
(2010)
Voyer et al.
(2008)
Voutilainen et al.
(2004)
Wagner et al.
(2008)
Whyte
(2005)
Wong
(2009)
Wulf
(2000)
EQIP*
D-Catch instrument
D-Catch instrument
Chart Review Form
Established protocol
Structure, process
and content
Structure, process
and content
Structure, process
and content
Content
Using yes/no and a 4-point scale to measure the completeness,
appearance, understandability and usefulness of documented
information for patients
Quantity and quality of nursing documentation such as adequacy
of admission information, presence and accuracy of nursing
diagnosis, interventions and outcome evaluations, logical
relationship in notes, linguistic correctness of documentation,
timeliness and date
See Paans et al. (2010a)
Documentation of impaired cognitive status
Patient assessment using several brief screening measures of
cognitive status
Agreement of different measures was addressed
An instrument Content Presence of different types of documentation, FHP assessment
items, nursing diagnosis, PES format, expected outcomes, nursing
interventions; internal linkages between steps of nursing process
A structured data
collection tool
Chart review using a
series of measures
The Senior Monitor
instrument
Content
Content and
process
Content
Presence of information according to demographics and 41 items
reflecting nursing assessment, nursing diagnosis, signs and
symptoms, aetiologies, care plan (goal and nursing interventions)
and progress notes
Accuracy of the documentation of delirium symptoms, namely the
sensitivity and specificity of the nursing notes, in comparison with
results of patient assessment by using CAM
Documentation in accordance to criteria under seven sections such
as planning nursing care, meeting the patient’s needs, care of
terminally ill patient and evaluating nursing care objectives
FMAT* Content Documentation of the postfall evaluation processes that consists of
three concepts: diagnosis, management and monitoring stages of
falls management guideline
Audit tool
Chart audit form
Audit form and score
sheet
Structure, process
and content
Structure, process
and content
Content
Concerning issues with documentation including essential
components of documentation and physical presentation of
documented data such as chronological order, date, time,
designation, illegal alteration of error, abbreviations and
meaningless phrases
Documentation of specific patient assessment and care data,
timeliness, clarity, documenting in a chronological order,
appropriate abbreviations and terminologies
Comparing the patient care summary with the results of patient’s
bedside assessment and interviews with nurses of provided care
Using 3-points scale to measure the documentation in accordance
with categories such as Level of Response (command and/or
interaction recall and visual stimuli) and Motor (location and
description of movement)
CAM, Confusion Assessment Method; CHF, Chronic Heart Failure; EPUAP, The European Pressure Ulcer Assessment Advisory Panel data
collection form; EQIP, The Ensuring Quality Information for Patient; ESCI, Ehnfors & Smedby’s comprehensiveness in recording instrument;
FHP, Functional Health Patterns; FIS, Fatigue Interview Schedule; FiCND, the Finnish Classification of Nursing Interventions (FiCNI); FiCNI,
the Finnish Classification of Nursing Diagnoses; FMAT, The Falls Management Audit Tool; MSA, multidimensional scalogram analysis;
NCPDCI, The Nursing Care Plan Data Collection Instrument; Q-DIO, Quality of Diagnosis, Intervention and Outcomes; NANDA, North
America Nursing Diagnosis Association; NIC, Nursing Intervention Classification; NOC, Nursing Outcome Classification; NNN, NANDA
Diagnosis, NIC and NOC; NoGA, not reported, PDAT, The Pain Documentation Audit tool; PES, problem, aetiologies and signs and symptoms;
PNDS, Perioperative Nursing Data Set; QOD, Quality of Nursing Diagnosis Instrument; RAPs, Resident Assessment Protocols;
TWEEAM, not reported; VIPS, an acronym formed from the Swedish words for wellbeing, integrity, prevention and security.
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part or all of the audit approaches described above. It was
common that more than one instrument was used in a study.
On the other hand, some instruments such as Ehnfors’
instrument (Bergh et al. 2007), the Cat-ch-Ing instrument
(Björvell et al. 2000) and the Q-DIO instrument (Müller-
Staub et al. 2009) were used in a range of studies. Details
about the instruments are summarized in Table 3.
Validation of instruments
Most of the studies reported the criteria generation for the
development of the instruments. Development was based
primarily on the nursing process model, previous audit
instruments, relevant local law and regulations, organizational
policies and practice guidelines/protocols/models, focus group
interviews with clinical experts, literature review, theoretical
frameworks, existing documentation forms and standardized
terminologies. The psychometric properties of the instruments
were reported with different levels of details in 54 of 77
publications (70%). The general results were as follows.
• Content validity: in nine studies, content validity of the
instruments was formally established (CVI > 0Æ80) with a
group of experts using a consensus model and focus
group approach (Müller-Staub et al. 2009). The number of
experts ranged from 3 to 20.
• Face validity: three studies measured face validity by having
experts review the instruments and judge their accuracy
(Lamond 2000, Eid & Bucknall 2008, Müller-Staub et al.
2009).
• Construct validity: In a study by Paans et al. (2010a),
construct validity was assessed on 245 records by explorative
factor analysis with principal components and
varimax rotation. In Lamond’s (2000) study, it was assessed
by comparing information obtained in the study with
measures identified from previous research to see the
correspondence between their varieties of classification
schemes. In the study by Larson et al. (2004), factor
analysis was performed by 20 auditors on 180 records
using principal component analysis for extraction and the
varimax orthogonal rotation of the instrument items to
determine the interdependencies between observed
variables.
• External validity: in the study by Gjevjon and Hellesø
(2010), external validity was strengthened through the
auditor acquiring in-depth knowledge from reading, practising
and testing the procedures before initiating the actual
study.
• Criterion-related validity: three instruments were tested for
their criterion-related validity using a second instrument
having similar objectives to the one being tested to audit a
proportion of sampled records (Björvell et al. 2000, Moult
et al. 2004, Tornvall et al. 2004).
• Internal consistency: ten publications reported the estimation
of internal consistency of the instruments. The resulting
Cronbach’s Alpha were acceptable as mostly above 0Æ70.
• Inter-rater reliability: forty studies reported the inter-rater
reliability of the instruments. This was evaluated through
involving two to eight persons to audit the same records
independently. One study reported that the inter-rater
reliability of the instrument was ensured by using the same
researchers (Considine & Potter 2006). The number of
records for estimation ranged from 4 to 310. About 10% of
total sample was used in eight studies. Inter-rater agreements
ranged from 40% to 100%, most were more than
80%. Cohen’s kappa values were estimated from 0Æ37 to
1Æ0 with the majority more than 0Æ7. In three studies, the
inter-rater reliability was estimated by calculating the
Spearman’s rank correlation coefficient and the values were
0Æ78 (P < 0Æ001) in the study by Tornvall et al.’s (2009)
and 0Æ90–0Æ98 in the study by Larson et al. (2004). Two
studies have reported the use of a coding book or user
manual and training for the auditors, which might help
establish interrater reliability (Junttila et al. 2010,
Thoroddsen et al. 2010).
• Intra-rater reliability was reported in five studies with
varying degrees of agreement, from fair to very good
(Larson et al. 2004, Helleso 2006, Müller-Staub et al.
2007, 2008a, Wagner et al. 2008).
• Usability: the usability of the instrument was tested in a the
study of Björvell et al. (2000) by three nurses auditing five
records in terms of understanding questions and the
phrasing of the instrument. The instrument was revised
after this process. In the study of Moult et al. (2004), the
instrument was read by parents, volunteers and clinicians
to test its usability.
Summary of study findings
The results of the nursing documentation audit are summarized
in two themes: issues of nursing documentation and study
interventions and their effects on nursing documentation.
Issues of nursing documentation
Quality of nursing documentation and audit
This review reveals many shortcomings in nursing documentation.
One of the major issues was the lack of documentation
concerning a series of nursing care topics. Many studies
showed the predominance of documentation of a biomedical
nature and insufficient recording of psychological, social,
cultural and spiritual aspects of care (Hegarty et al. 2005,
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N. Wang et al.
Altken et al. 2006, Gebru et al. 2007, Gunhardsson et al.
2007, Tornvall et al. 2007). There was also inadequate
documentation about assessment of patients’ preferences and
needs for knowledge, previous health behaviour, general
health perceptions and quality of life (Cadd et al. 2000, Davis
et al. 2000, Laitinen et al. 2010). In addition, patient
teaching was rarely evidenced in the records (Karkkainen &
Eriksson 2003, Fribeg et al. 2006).
A number of studies showed inadequate documentation of
the five steps of the nursing process (Ehrenberg & Birgersson
2003, Bergh et al. 2007, Gjevjon & Hellesø 2010). In regard
to specific care issues, identified deficiencies included insufficient
documentation of assessment and the rare use of an
assessment tool for pain and cognitive impairment (Eid &
Bucknall 2008, Hare et al. 2008). Gaps were also found in
documentation of assessment, treatment and prevention of
pressure ulcers (Gunningberg et al. 2000, Ehrenberg &
Birgersson 2003, Baath et al. 2007), assessment of physical
characteristics of wound (Gartlan et al. 2010), specific
assessment and interventions for older patients with chronic
heart failure (Ehrenberg et al. 2004), nursing actions and
evaluation for patients in palliative care (Gunhardsson et al.
2007), and assessment of mental ability and interventions to
support independent functioning for patients with dementia
(Souder & O’Sullivan 2000, Voutilainen et al. 2004). Additionally,
some studies showed a lack of documentation of
specific patient data such as vital signs, pupil reaction and
mental state, the diagnosis for hospitalization and electrocardiography
ECT results.
Issues were also found with the use of standardized nursing
terminologies. Paans et al. (2010b) found inaccurate documentation
of nursing diagnoses and interventions, despite the
use of nursing process-based documentation systems. These
included lack of PES format with nursing diagnoses, outcome-oriented
selection of nursing interventions and incoherence
between steps of nursing process. Junttila et al.
(2010) identified deficiencies in the clinical usability of
nursing diagnoses during the intra-operative phase of care.
The use of various local diagnostic systems was shown in
Karlsen’s (2007) study.
In relation to the structure and process features of nursing
documentation, problems included inconsistence in terminologies
and timing for documentation (Wong 2009), abstract
and unclear recording, inappropriate phrasing of statements
(Karlsen 2007); and documenting under a wrong section
(Hayrinen & Saranto 2009). Issues identified by Ammenwerth
et al. (2001) included incomplete documentation and
poor legibility with paper-based documentation and unspecific
and too long care plan with electronic records. Importantly,
poor concordance between record content and results
from patient assessment, interviews with patients and nurses
and observations of nurses’ performance (Lamond 2000,
Ehrenberg & Ehnfors 2001, Gunningberg & Ehrenberg
2004, Voyer et al. 2008, Marinis et al. 2010) indicated that
data documented in the nursing records were not fully
adequate and accurate to reflect reality.
Study interventions and their effects on nursing
documentation
In 25 analytic studies, various study interventions were
implemented and their effects were assessed. These interventions
included: electronic health record systems (EHRs)
(Ammenwerth et al. 2001, Mahler et al. 2007), standardized
documentation systems such as the VIPS model (Darmer et al.
2006), a menu-driven incident reporting system (Wagner et al.
2008), standardized nursing languages (Müller-Staub et al.
2007), changing ward organization (Hansebo & Kihlgren
2004), nursing process model (Ehrenberg & Ehnfors 2001),
ED nursing documentation standards (Considine & Potter
2006), specific nursing care theories (Karkkainen & Eriksson
2005, Aling 2006), education on specific care issues such as
postoperative pain (Dalton et al. 2001) and a mixture of some
of these interventions.
Nursing documentation could be improved to some extent
by the study interventions, as shown in most of the study
results, although at times no effect or even some negative
effects were reported. The implementation of EHRs integrated
with standardized structure and language could
improve the completeness of common mandatory fields
(Helleso 2006), the comprehensiveness of documentation of
the nursing process (Larrabee et al. 2001, Daly et al. 2002,
Darmer et al. 2006, Gunningberg et al. 2009), the use of
standardized languages (Larrabee et al. 2001) and the
recording of specific items about particular patient issues
(Gunningberg et al. 2009). Improvement was also noted in
the relevance of the message (Helleso 2006, Tornvall et al.
2009) and structure and process features of documentation
such as dating, signing, abbreviations and symbols (Rykkje
2009, Mahler et al. 2007).
Education and organizational support for documentation
of the nursing process and the use of standardized nursing
languages (NNN) could improve documentation. This helped
nurses understand nursing process theory and improve
clinical reasoning skills in conducting systematic nursing
assessment, formulating accurate nursing diagnoses, planning
concrete and effective nursing interventions and documenting
observable nursing outcomes (Nilsson & Willman 2000,
Björvell et al. 2002, Florin et al. 2005, Müller-Staub et al.
2007, 2008b).
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Education was effective in the study by Dalton et al. (2001)
about documentation of acute postoperative pain management,
but had no obvious effect in Gunningberg’s (2004)
study about documentation of ulcer prevention. Considine
and Potter (2006) showed that a series of written ED
standards augmented by an in-service education session
could improve initial nursing assessment. Additionally, body
mass index tables placed in examination rooms could
encourage nurses to document BMI, thus leading to a
statistically significant increase in the diagnosis of obesity
(Lemay et al. 2004).
In regard to nursing theories, Karkkainen and Eriksson
(2005) reported that introducing Eriksson’s caring theory to
the clinical context could improve the recording of the
patient’s experiences and health behaviour. Aling’s (2006)
study showed that introducing five different nursing theories
was associated with the increase in the documentation of
nursing history and status upon patients’ arrival.
Discussion
This review constitutes a cross-sectional survey of nursing
documentation audit studies with different designs and study
aims. A large number of publications were included. Its
strength is that the review provides an overview of current
measurement of nursing documentation, from which the
definitions, measurement approaches and issues with the
quality of nursing documentation can be identified. In
addition, the review identifies the means by which the quality
of nursing documentation could be improved.
While conceptually comprehensive, less critical was a
limitation of the review. The results of the review were
briefly presented without describing many details in the
original papers. There was no formal appraisal of study
quality, so various types of potential bias were not assessed.
The review also lacks a critique of nursing documentation
audit approaches. The psychometric properties of the audit
instruments were generally presented without details about
each individual item and without statistical significance data.
This review identifies a range of nursing documentation
audit instruments. Four instruments were most commonly
used in the studies: Ehnfors and Smedby’s comprehensiveness-in-recording
instrument, the Cat-ch-Ing instrument, the
Q-DIO instrument and a protocol including strategies for
prevention and treatment of pressure ulcers. The former three
were developed in 1993, 2000 and 2007 respectively. They
may reflect the development of nursing documentation over
the past two decades, from the use of a nursing process model
to the implementation of standardized nursing documentation
systems, then to the application of standardized nursing
Quality of nursing documentation and audit
terminologies. The latter was a typical instrument for
measuring documented care content in relation to a particular
clinical issue. In addition, a special instrument was used
to measure the quality of information for patients rather than
for communication among health professionals (Moult et al.
2004). These instruments, together with other instruments
identified, addressed different aspects of nursing documentation
quality. They applied various approaches and reflected a
complete picture of the quality of nursing documentation as
perceived by researchers from different countries.
The audit approaches mainly addressed three natural
dimensions of nursing documentation: structure or format,
process and content, which constitute a complete profile of
nursing documentation. Quality structure and format of
nursing documentation are essential in ensuring that patients’
data are presented in a friendly way to facilitate nurses’ or
other health professionals’ easy access to information essential
for clinical decision-making. A proper process of data
capture is expected as it enables documentation of valid and
reliable information about patients and care. The content of
nursing documentation should be the central focus of audit
because of its implications for nursing care practice. In sum,
nursing care should be fully expressed in the content of the
nursing documentation, in a quality structure and format and
through an appropriate documentation process.
The accuracy of documentation content in relation to
patients’ actual conditions and the care given is an important
process feature of documentation quality. If there is no
assurance of nursing documentation holding valid and
reliable data, there would be no value to discuss its quality.
The concordance between documentation content and
patient assessment or interviews with nurses and patients
can reflect the accuracy of data. However, this corroboration
of evidence from different sources rather than in situ
observation is still an indirect method to approve the
accuracy of nursing documentation and has potential bias.
The content of nursing documentation, which contains
evidence about care, is closely associated with nurses’
professional expertise. Urquhart et al. (2009) stated that
nursing documentation had been used to support different
philosophies of nursing practice. While the theoretical
knowledge and concepts the nurses have of nursing can be
embodied in the written text, the evaluation of nursing
documentation should have implications for the advancement
of nursing profession. The two basic quality elements,
comprehensiveness and appropriateness of nursing documentation,
define how well the content of nursing documentation
should be for each step of the nursing process. Important
information sources included standardized nursing terminologies,
clinical policies or guidelines and standardized nursing
Ó 2011 Blackwell Publishing Ltd 13

N. Wang et al.
What is already known about this topic
• Quality nursing documentation facilitates better care
through enabling effective communication between
nurses and other caregivers.
• Stages in the development of nursing documentation
have included the introduction of the nursing process
model to the clinical setting, application of electronic
documentation systems and the use of standardized
nursing languages.
• Definitions of nursing documentation quality can differ
because of variations in practice across countries and
settings.
What this paper adds
• The paper is a comprehensive review and presents
description of nursing documentation audit instruments
that have acceptable psychometric properties.
• Flaws in nursing documentation include lack of
documentation on psychological and social aspects of
care; insufficient documentation about the steps of the
nursing process and lack of specific data in relation to a
particular clinical care issue.
• Approaches to improving nursing documentation
include the use of electronic health records,
standardized documentation systems, application of
specific nursing theories, education and organizational
changes.
Implications for practice and/or policy
• The quality of nursing documentation has multiple
dimensions, which can be evaluated by applying various
instruments and influenced by using technological,
educational and organizational interventions.
• Factors leading to varying practice and flaws in
documentation quality and their effects on nursing
practice and patient outcomes need to be further
investigated.
• Attention needs to be paid to the accuracy of nursing
documentation in comparison with reality of practice.
documentation systems with preformatted items or
keywords. These information sources support nurses in
documenting nursing process and in making decisions on
care-delivery to the patients. They can also generate quality
criteria for the evaluation of documentation content.
The shortcomings in nursing documentation included
deficiencies at different levels of the content. This indicated
that nursing care was not fully expressed in the records, so
written communication between different caregivers about
patients was inadequate. Furthermore, inaccurate formulation
of nursing diagnoses and incoherence in documentation
of nursing process (Paans et al. 2010b) have reflected the
nurses’ lack of knowledge and skill in clinical reasoning and
connecting the reasoning process to nursing process.
The structure and process of nursing documentation can be
improved by the implementation of standardized electronic
nursing documentation systems. Approaches such as the
implementation of standardized documentation systems with
prestructured keywords, standardized nursing terminologies,
nursing theories and nursing practice standards or guidelines
were shown to help improve the content of nursing documentation.
Conclusion
Nursing documentation has continuously developed with
increasing research on the nursing process. In the reviewed
studies, the concept of quality of nursing documentation has
been operationally defined by various audit instruments,
which have focused on different aspects of documentation
quality and revealed variations in practices worldwide. All
the audit studies use local standards to evaluate local
practice. It may not be practical to seek a universal
instrument that fits all study settings because of the use of
different nursing documentation systems and terminologies
based on the local circumstances. However, the underlying
factors causing this and its effects on patient outcomes need
to be addressed in further research.
Several other areas of documentation would also benefit
from further research. The causes of documentation flaws
and their effects on patient outcomes need to be investigated.
More attention needs to be paid to the concordance between
nursing documentation and care delivery on the floor. This is
especially important with increasing application of electronic
documentation systems in health care with capacity to
increase aggregation and the accuracy of data by a more
structured and uniform format of data organization. Examination
of causes for inaccuracy of data and factors leading to
improvement should shed light for better system designs.
There is a need to evaluate the quality of audit instruments
from conceptual, theoretical and technical perspectives.
Conceptual analysis of measurement standards helps to
improve understanding of the definition of quality of nursing
documentation and to clarify ambiguous concepts and reach
precise operational attributes. Theoretical analysis can help
determine whether audit standards are relevant to nursing.
Critiques of measurement techniques used in audit instru-
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JAN: REVIEW PAPER
Quality of nursing documentation and audit
ments are essential in determining whether instruments are
valid and reliable and can produce strong evidence reflecting
the quality of nursing documentation.
Nursing documentation has come a long way but still has
deficiencies. Further research and more consistent application
of established standards will lead to improvements, with
associated benefits for practice management and patient
outcomes.
Funding
This research is a part of a PhD project supported by
Australia Research Council (ARC) industry linkage project
LP0882430. Five Australian aged-care organizations: Aged
and Community Services Australia, Illawarra Retirement
Trust, RSL Care, Uniting Care Ageing South Eastern Region
and Warrigal care partially funded the project.
Conflict of interest
The authors declare that there is no conflict of interest.
Author contributions
NW, DH and PY were responsible for the conceptualization
and design of the study. NW collected the data, performed
the data analysis and drafted the manuscript. PY reviewed the
papers included and the data extraction. DH and PY
supervised the study and made intellectual input through
critical revisions to the manuscript.
Supporting Information Online
Additional Supporting Information may be found in the
online version of this article:
Table S1. Characteristics of descriptive studies
Table S2. Characteristics of analytic studies
Table S3. Auditing instrument and measurement details
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials supported
by the authors. Any queries (other than missing material)
should be directed to the corresponding author for the article.
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JAN: REVIEW PAPER
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Ó 2011 Blackwell Publishing Ltd 17

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