Jefferies D, Johnson M, Griffiths R. International Journal of Nursing Practice 2010; 16: 112–124
A meta-study of the essentials of quality nursing documentation
The aim of this study was to synthesize all relevant information about nursing documentation and present the essential aspects of quality nursing documentation. Literature searches, limited to the English language, were conducted on both CINAHL (1982 to week 3, April 2008) and MEDLINE (1996 to April 2008) using the following search terms: attitude, audit, care, culture, documentation, guideline health, in service, legal, liability, medical, nurses, nursing, organizational, patient, personnel, planning practice, quality, records, research and training. One hundred and seventy-one papers were reviewed for their relevance to the clinical question. Twenty-eight articles were read by two researchers. Data informing the clinical question were extracted and categorized into key concepts by an analysis of similarities. The seven major themes (essentials) of quality nursing documentation were identified. This paper has reviewed contemporary literature, research evidence and local policies to identify the seven essential components of quality nursing documentation. Some of the barriers or more controversial aspects of the final policy are described.