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

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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