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

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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