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

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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