Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review
Article first published online: 6 APR 2011
© 2011 Blackwell Publishing Ltd
Journal of Advanced Nursing
Volume 67, Issue 9, pages 1858–1875, September 2011
How to Cite
Wang, N., Hailey, D. and Yu, P. (2011), Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. Journal of Advanced Nursing, 67: 1858–1875. doi: 10.1111/j.1365-2648.2011.05634.x
- Issue published online: 9 AUG 2011
- Article first published online: 6 APR 2011
- Accepted for publication 22 January 2011
- evaluation approaches;
- nursing documentation;
- quality criteria;
- systematic review
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 67(9), 1858–1875.
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.