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Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review
Ning Wang, David Hailey & Ping Yu
Accepted for publication 22 January 2011

Correspondence to P. Yu: e-mail: ping@uow.edu.au Ning Wang RN PhD Candidate Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia David Hailey PhD Research Fellow Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia Ping Yu PhD Senior Lecturer, Research Director Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia

W A N G N . , H A I L E Y D . & Y U P . ( 2 0 1 1 ) Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. Journal of Advanced Nursing 67(9), 18581875. doi: 10.1111/j.1365-2648.2011.05634.x

Abstract
Aims. This paper reports a review that identied 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 reected 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 identied and their psychometric properties were described. Flaws of nursing documentation were identied 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 aws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement. Keywords: audit, evaluation approaches, instruments, nursing documentation, quality, quality criteria, systematic review

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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 (Bjo rvell et al. 2000, Voutilainen et al. 2004). Nursing documentation is dened as the record of nursing care that is planned and given to individual patients and clients by qualied nurses or by other caregivers under the direction of a qualied 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 rst 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 (Bjo rvell 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 Classication of Nursing Practice (ICNP) and the International Nursing Diagnoses Classication (NANDA International). Standardized nursing languages provide common denitions of nursing concepts and allow for theorybased and comparable nursing data to emerge. Therefore,
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they promote shared understanding and continuity of care and make it possible to use records for research and management purposes (Mu ller-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, Mu ller-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 denition 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 reecting 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 (Mu ller-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 ll 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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their measurement criteria and describing issues with nursing documentation identied by auditing.

1763 citations identified from electronic search, and screened 219 citations identified from 4 reviews, and screened

Design
A mixed-method systematic literature review was conducted, following the guidelines of the Centre for Reviews and Dissemination (2008).

1797 citations excluded

185 potentially relevant publications retrieved for scrutiny 108 publications excluded

Search methods
A search for relevant publications was mainly undertaken in November and December 2009 on seven electronic databases (CINAHL, the Cochrane Library, Health Reference Center, ProQuest Nursing, Wiley InterScience, Medline 1996 and Nursing Resource Centre). The search terms nursing documentation, nursing records, audit, evaluation and quality, both singly and in combination, were used to identify articles. The search was restricted to articles published in English from 2000 to 2009. However, a new search for update evidence was carried out on August 2010. The following criteria were used in selecting papers: Inclusion criteria Publications of nursing documentation audit studies. Reports on the development or testing of nursing documentation audit instruments. Any type of nursing documentation system, either paperbased, electronic, terminologically standardized, preformatted or structured. Any component of nursing documentation such as nursing assessment forms, care plan and progress notes. Audit studies conducted in any setting: hospital, aged care facility and community etc. Exclusion criteria Papers not dealing with nursing documentation. Review and contextual papers, editorials, letters and case studies. Publications about nursing documentation requirements or guidelines. Papers on issues of nursing documentation other than its quality, e.g. development of documentation systems, factors affecting the quality of documentation and how to complete nursing documentation. Papers on evaluating nursing documentation through surveys and interviews. Papers concerning documentation of health professions other than nursing. Duplicated papers on the same study.
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77 publications included

Figure 1 Publication search process.

Search outcome
The titles and abstracts from the primary search were manually screened by the rst author. Reference lists from good quality literature review were also scrutinized for relevant articles. Uncertain papers were checked by the third author to determine their relevance. Seventy-seven papers were nally included in the review following a screening process as shown in Figure 1.

Quality appraisal
As determining the methodological adequacy of studies was not essential for the purpose of the review, a formal quality assessment of review studies was not conducted; however, some consideration was given to prioritizing studies for analysis according to the level of detail given on the audit instruments, and the relevancy and signicance of auditing approaches to nursing practice.

Data abstraction
Extracted data were placed in an Endnote le. These data included study aim, design, study intervention, country of origin, setting, sample size, documentation audit instrument, quality criteria, source of criteria, validation of instrument, approach of evaluation and key ndings of the studies.

Synthesis
Given the purpose of the review, meta-analysis was neither appropriate nor feasible for data synthesis. The papers were grouped by the type of studies. A narrative synthesis of extracted data was undertaken using tables with emerging thematic headings.
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Results
Characteristics of studies
The 77 eligible papers consisted of different types of studies carried out in various healthcare settings across 15 countries. The sample sizes ranged from 15 to 13,776 presented as the number of records, number of patients, number of documentation items and number of patient visits. Nursing documentation was audited for different purposes. These were either explicitly or indirectly stated by the authors primarily to address the quality of description of care or the quality of described care. Summarized information on the studies is shown in Table 1. Detailed information is displayed in Tables S1S3.

Different auditing approaches were identied in the study instruments. These approaches were classied into three thematic categories, which reected natural dimensions of nursing documentation: structure and format, process and content. In 47 studies, a single approach was used, while a mixture of approaches was applied in the other. Detailed quality criteria are presented in Table 2. Different types of auditing approaches are displayed in Table 3.

Approach concerning documentation format and structure

The approach concerning the format or structure dealt with constructiveormaterialfeaturesratherthanthemessageofdata. Itfocusedondatasphysicalpresentationssuchasthequantityof records, completeness, legibility, readability, redundancy and the use of abbreviations. Twenty studies applied this approach.

Approaches to nursing documentation audit

Nursing documentation was assessed by quantitative and qualitative content analysis methods, mostly with one or more formally dened instruments. Commonly, each nursing record was graded quantitatively using yes/no tick box or 3, 4, 5 and/or 6 point Likert scales. A few studies, however, used qualitative content analysis methods such as critical discourse analysis (Karlsen 2007), constant comparative analysis (Laitinen et al. 2010) and a case-by-case approach to draw out themes from nursing records (Hegarty et al. 2005).

Approach concerning documentation process

The process approach focused on procedural issues of capturing patients data such as signature, designation, date, timeliness, regularity of documentation and its accuracy to reality. The accuracy of documentation was measured by the concordance between different notes, or between documentation content and the results of patient assessment (Gunningberg & Ehrenberg 2004, Voyer et al. 2008), nurses self reports (Lamond 2000), interviews with nurses and patients (Ekman & Ehrenberg 2002, Wong 2009) and observation of nurse performance (Marinis et al. 2010). The process approach was used in 23 studies.

Table 1 Summary of included publications (n = 77)

Study type (number of studies) Descriptive studies (45) Analytic studies (25): pre-post intervention test (12), quasi-experimental studies (7), randomized controlled trials (3), cluster-randomized trial (1), prospective (1), stratied and randomized intervention study (1), prospective cohort study (1) Instrument development and testing reports (7) Sweden (27), USA (11), Australia (8), Finland (8), Switzerland (4), Norway (4), UK (3), Germany (2), Canada (2), Iceland (2), Italy (1), Netherlands (2), Ireland (1), Rwanda (1), Denmark (1) Auditing studies: Hospital (51), long-term care (7), primary care (6), community care (4), school health centre (1), mixture of hospital and nursing home (1) Reports of instrument development and testing (7): six instruments were reported in the seven papers and were developed based on hospital settings

Approach concerning nursing documentation content

The content approach focused on the meaning of data about care process. This approach was adopted in nearly all of the studies included, where the content of documentation was reviewed in general or specically in relation to a range of focused care issues. When nursing care or nurses knowledge about care was concerned, the authors made judgments based on an underlying assumption that the information documented in the nursing records was complete and accurately reecting reality. Two quality aspects of documentation content were assessed in this approach: what documentation has recorded and how good it is.

Countries of origin (number of studies)

Study setting (number of studies)

What has documentation recorded?

This approach referred to the comprehensiveness of documentation content. It concerned the presence of data about a
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Table 2 Quality criteria of nursing documentation

Category Quality criteria of documentation structure and format Quality criteria Completeness, quantity, legibility, appearance, plausibility, patient identication, abbreviations, correction of error, linguistic correctness (objective or factual language and scientic terms), chronological report of events, the colour of the ink, blank spaces and gaps within the text, documentation in a correct section, the phrases of recording, succinct and clear language, avoidance of use of jargon or technical terms Signature, date, timeliness, chronological report of events, designation, regularity, accuracy in comparison with reality and accessibility Presence of specic types of documentation (e.g., nursing history and discharge note), presence of specic variables (e.g., patients background information, cause of admission, address of discharging unit), comprehensiveness of ve phases of nursing process, scope of care (e.g., FHP), presence of information about specic care topics (e.g., teaching and learning of the patient, emotional and physical support of the patient or family, patient preference)

Quality criteria of documentation process Quality criteria of documentation content Comprehensiveness of description of care (or care)

Appropriateness of description of care (or care) s Nursing assessment

Nursing problem/diagnosis Goal Intervention

s s

s s

Evaluation General

Presence of specic assessment variables in relation to the problem according to guideline (e.g. grade, size and location and risk assessment for pressure ulcer), use of specic keywords dened in the system in relation to the problem concerned (e.g., pedagogically related assessment keywords dened in the VIPS model). Adequacy or accuracy of problem statement in accordance with NANDA standardised terminologies (e.g., PES format), the relevance within PES Being clear rather than abstract and vague Presence of particular types of intervention in relation to the nursing problem according to guidelines (e.g., uid intake, turning schedule for pressure ulcer), use of specic keywords dened in the system in relation to the nursing problem (e.g., intervention keyword of health promotion for school nursing programmed in the computer system), presence of NIC interventions Presence of NOC (nursing outcome classication) outcomes Internal relationship with ve steps of nursing process

care process at a general level, without considering its logical connection to a particular care issue or the patients condition. Issues measured included whether documentation contained certain types of data such as nursing history, nursing status (Bjo rvell et al. 2002, Gjevjon & Helles 2010), baseline data and discharge summary (Mbabazi & Cassimjees 2006); whether documented nursing care was sufcient to the scope of care needs dened by the study, such as the Health-Related Quality of Life (HRQOL) models seven dimensions (Davis et al. 2000); and most commonly, whether information about the ve steps of nursing process was adequately documented (Ehrenberg & Birgersson 2003, Bjo rvell et al. 2002, Mahler et al. 2007, Thoroddsen et al. 2010, Hayrinen et al. 2010).

(Gunningberg et al. 2009) or postoperative pain (Idvall & Ehrenberg 2002). Documentation content about each step of the nursing process was measured through seeking data specically related to the concerned clinical issue: could be particular keywords preformatted in a standardized documentation system (Bergh et al. 2007), variables of clinical policies or guidelines (Considine & Potter 2006, Junttila et al. 2010, Gartlan et al. 2010) or standardized terminologies (Lunney 2006, Hayrinen et al. 2010). The structure and format of the diagnostic statement (PES format: problem, aetiologies and signs and symptoms) and the internal linkage between the ve phases of the nursing process (Florin et al. 2005, Mu ller-Staub et al. 2009, Paans et al. 2010b) were also covered by this approach.

How good is nursing documentation content?

This approach addressed the appropriateness of nursing documentation or documented care at a level specic to a particular clinical care issue such as pressure ulcers
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Nursing documentation audit instruments

The majority of papers described the development or use of nursing documentation auditing instruments, which adopted
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Table 3 Nursing documentation audit instruments and measurement details

Reference Instrument Audit approaches Content Measurement details

Bergh et al. (2007)

Ehrenberg & Birgersson (2003) Idvall & Ehrenberg (2002)

ESCI* Quantitative and qualitative keywords analysis ESCI* Nominal scale ESCI* Tentative model NANDA* characteristics of acute pain ESCI* Record audit ESCI* EPUAP *

Content

Content

Using ve-point scales to measure the comprehensiveness of documentation of ve steps of nursing process Quantity of documentation of pedagogically related keyword; presentation in thematic form See Bergh et al. (2007) Documentation of specic signs and symptoms related to leg ulcer and their accordance with guidelines See Bergh et al. (2007) Documentation of indicators/categories related to how to conduct postoperative pain management Documentation of pain characteristics

Ehrenberg et al. (2004) Gunningberg & Ehrenberg (2004)

Content

Content and process

Gunningberg (2004) Gunningberg et al. (2009) Gjevjon & Helles (2010)

ESCI* Record audit protocol ESCI* EPUAP* Level one VIPS* categories Modied ESCI*

Content

Content

Content

Gunningberg et al. (2000) Gunningberg et al. (2001) Baath et al. (2007) Fribeg et al. (2006) Bjo rvell et al. (2000)

Audit protocol ESCI* Audit protocol Audit protocol ESCI* Protocol ESCI* Cat-ch-Ing instrument

Content

Content Content Content

See Bergh et al. (2007) Documentation of specic aspects of nursing assessment and nursing interventions for patients with CHF See Bergh et al. (2007) Documentation of patients background data, pressure ulcer grade, size and location, risk assessment and preventive care Comparing results of documentation audit with results of patient assessment See Bergh et al. (2007) Documentation of risk factors, risk assessment, prevention and treatment of pressure ulcer See Bergh et al. (2007) Documentation of patient background data, pressure ulcer grade, size and location, risk assessment and nursing interventions Presence of documentation according to level one categories of VIPS* model such as nursing history, nursing status and dis charge notes An additional scale of 0 to the original ve-point scales of ESCI* instrument concerning the ve steps of nursing process Documentation of strategies for prevention and treatment of pressure ulcers See Bergh et al. (2007) See Gunningberg et al. (2000) See Gunningberg et al. (2000) See Bergh et al. (2007) Documentation of patient teaching; patients need for knowledge and nurses teaching interventions See Bergh et al. (2007) Using four-point scales or yes/no to measure the quantity and quality of documentation of nursing process; the use of VIPS keywords; the presence of date, signatures and clarication of signatures; linguistic correctness and legibility See Bjo rvell et al. (2000) See Bjo rvell et al. (2000) See Bjo rvell et al. (2000)

Structure, process and content

Bjo rvell et al. (2002) Tornvall et al. (2004) Tornvall et al. (2007)

Cat-ch-Ing Instrument Cat-ch-Ing instrument Cat-ch-Ing audit instrument

Structure, process and content Structure, process and content Structure, process and content

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Table 3 (Continued)
Reference Instrument Audit approaches Structure and content Content Measurement details

Aling (2006)

Tornvall et al. (2009)

Cat-ch-Ing instrument (modied) Cat-ch-Ing instrument (part) Record audit for clinical issues

Darmer et al. (2006) Nilsson & Willman (2000)

Cat-ch-Ing instrument (modied) Cat-ch-ing instrument (part) NoGA instrument* Modied Cat-ch-ing instrument Modied Cat-ch-Ing instrument Quantity of nursing documentation Cat-ch-Ing instrument (part) QOD instrument* The Cat-ch-Ing EPI instrument

Structure, process and content Structure, process and content

Rykkje (2009) Hayrinen et al. (2010)

Structure, process and content Structure, process and content

Florin et al. (2005)

Content

Larson et al. (2004)

Process and content

Mu ller-Staub et al. (2009) Mu ller-Staub et al. (2008a) Mu ller-Staub et al. (2007) Mu ller-Staub et al. (2008b) Altken et al. (2006)

Q-DIO instrument*

Content

Q-DIO instrument* Q-DIO instrument* Q-DIO instrument (part) * 3-part medication audit instrument Checklist

Content Content Content Content

Questions related to discharge note, signing and using VIPS keywords were removed. Language, grammar and abbreviations were concerned. Maximum of 57 points instead of 80 Audit of date, signatures; clarication of signatures and legibility were excluded Documentation of important clinical nursing issues with regard to aspects in relation to leg ulcer such as health history, knowledge/ development, breathing/circulation, nutrition, wound status, rel evant interventions and evaluation The item of nursing discharge note in the Cat-ch-Ing instrument was excluded; the measurement of nursing diagnosis item was simplied The rst part of the instrument (preliminary?) Item concerning clarication of signature was excluded. Details not fully clear Quantity of the ve steps of nursing process Adding two items related to the quantity and quality of nursing transfer note and nursing discharge summary See Bjo rvell et al. (2000). Adding measure of the use of nursing classications (FiCNI and FiCND) and the relationships between classication Frequency of the nursing diagnoses, aims for care, nursing interventions and nursing outcomes Only the quantity and quality variables of nursing diagnosis were used Structure and format of diagnostic statement and the relevance in PES Using four-point scale to measure the quantity and quality of documentation in discharge note concerning given care, continued nursing needs, planned care, and general data including signature and data Using 3- and 5-point scales to measure the quality of documented nursing diagnosis (as process and product), interventions, out comes and their internal relationships See Mu ller-Staub et al. (2009) See Mu ller-Staub et al. (2009) See Mu ller-Staub et al. (2009). The category nursing diagnosis as process was excluded Documentation of patients demographic information, medications and detailed data about nurses medication management including assessment, planning care, medication administration and evaluation of outcomes Objective quality measurements (e.g. number of stated nursing aims, completeness) and subjective quality measurements (e.g. legibility, plausibility, overall quality judgment) Documentation of admission assessment about patients home bowel care management and preferences for care Documentation of nineteen parameters of initial nursing assessment, historical variables and primary survey assessment Documentation of health status in accordance with seven dimensions of the model

Ammenwerth et al. (2001) Cadd et al. (2000) Considine & Potter (2006) Davis et al. (2000)

Structure and content Content Content Content

Proforma Standardized audit tool HRQOL* model

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Table 3 (Continued)
Reference Instrument Audit approaches Content Structure Content Measurement details

Dalton et al. (2001) Daly et al. (2002) Delaney et al. (2000) Dochterman et al. (2005) Ehrenberg & Ehnfors (2001)

Audit instrument Standardized instruments An auditing tool

Documentation of items about pain assessment and management: e.g. pain history, type and intensity, and follow up evaluation Quantity of nursing diagnosis and nursing interventions Presence of data in accordance with items listed in the instrument including NANDA diagnostic label, dening characteristics and related factors of impaired physical mobility Amount and patterns of NIC* interventions used for patients with heart failure, hip fracture procedure and risk of falls Documentation with regard to the topics such as patients problems relating to urinary incontinence, mental condition, mobility, nutritional intake, skin condition and uid intake Concordance between audit results and the results of interviews with residents and nurses concerning the same topics Patient demographic data, diagnosis, co-morbidities, type of operation, information on pain assessment, management and education 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 Identication 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, patients overall status, ongoing management plan; objective assessment Documentation of the VIPS keywords; presentation in appropriate category in the theoretical framework of palliative care Documentation of patients demographic information, cognitive and behavioural changes, preexisting, conrmed diagnosis of dementia, confusion on admission, cause of confusion and behavioural descriptors and nurses use of formal cognitive assessment tools 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

NIC* (250/514) interventions Record audit protocol

Content Content and process

Eid & Bucknall (2008) Ehrenberg et al. (2001) Ekman & Ehrenberg (2002) Gartlan et al. (2010) Gebru et al. (2007)

PDAT*

Content

Approaches derived from a literature review FIS*

Structure, process and content Process and content Content

A paper-based audit tool Qualitative content analysis Leiningers Sunrise Model Documentation audit tool

Content

Gregory et al. (2008)

Content (structure and process?)

Gunhardsson et al. (2007) Hare et al. (2008)

Qualitative and quantitative content analysis Tickbox list

Content

Content

Hansebo & Kihlgren Quantitative content (2004) analyses RAPs* Intervention guidelines Hayrinen & Saranto (2009) Narrative content analysis

Structure and content

Content

Hegarty et al. (2005) Quantitative and qualitative data analysis

Content

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Table 3 (Continued)
Reference Instrument Audit approaches Structure and content Measurement details

Helleso (2006)

TWEEAM instrument* Language functions of Svennevigs typologies

Irving et al. (2006)

A Focucauldian approach to discourse analysis List of nursing diagnoses in the PNDS Categorization table

Structure and content

Junttila et al. (2010)

Content

Using a three-point scale to measure the completeness of items in the discharge notes in accordance with six sections of the instrument; the completeness of 12 keywords in the section of Patients Current Status; data of discharge notes Three language functions (expression, interpersonal and referential) Qualitative analysis; medical, nursing and informal; types, content/message, and terminologies of documentation of assessment, the tone of nurses expression and its implications, nursing models underlying nursing documentation Prevalence of nursing diagnoses listed in the PNDS by perioperative phases Documentation of planning, implementation and evaluation of perioperative care and additional information with subcategories such as physical and psychological safety and asepsis in perioperative care The nurses language expression in assessing patients needs, formulating goals and making a care plan, diagnostic systems and documentation parlance Four-point scale to measure the documentation according to categories such as patient analysis and its recording, patient teaching and learning, evaluation of the nursing care, prevention of complications and errors See Karkkainen & Eriksson (2003) Documentation of BMI calculation, an obesity diagnosis, and inclusion of heights and current weights Documentation of comprehensiveness variables concerning patient assessment; concordance of information between the patient notes and the nurse shift report Documentation of NANDA diagnoses, diagnoses relating to health promotion, NIC* interventions and NOC* outcomes Documentation of VIPS keywords covering 10 key areas of leg ulcer care and treatment Concepts obtained through a series of qualitative data analysis steps were organized into four components of the paradigm model: conditions, interaction, emotions and consequences Documentation of nurse assessments of patient outcomes (NASSESS), achievement of patient outcomes (NGOAL), nursing interventions done (NQUAL) and routine assessment (e.g. vital signs) Quantity and quality aspects of description of the course of care, participation of the patient in care planning, formal aspects of data entry, plausibility and value-free documentation Consistency between recorded and observed nursing assessment activities and interventions Documentation of baseline data, diagnosis, treatments, evaluations and discharge summary; regularity of vital sign measurement, use of scientic terms and chronological report of events

Junttila et al. (2000)

Content

Karlsen (2007)

Critical discourse analysis Lukanders Nursing Audit instrument

Structure and content Content

Karkkainen & Eriksson (2003)

Karkkainen & Eriksson (2005) Lemay et al. (2004) Lamond (2000)

Lukanders Nursing Audit instrument Abstraction tool

Content Content

Coding scheme of MSA* NNN* Checklist Strauss and Corbins paradigm model NCPDCI*

Content and process Content Content Content

Lunney (2006) Lagerin et al. (2007) Laitinen et al. (2010) Larrabee et al. (2001)

Structure and content

Mahler et al. (2007) Marinis et al. (2010) Mbabazi & Cassimjee (2006)

Quantitative and qualitative checklist Checklists 3-section quality measurement checklist

Structure, process and content Content and process Structure, process and content

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Table 3 (Continued)
Reference Instrument Audit approaches Structure, process and content Structure, process and content Measurement details

Moult et al. (2004) Paans et al. (2010a)

EQIP*

D-Catch instrument

Paans et al. (2010b) Souder & OSullivan (2000) Thoroddsen & Ehnfors (2007) Thoroddsen et al. (2010)

D-Catch instrument Chart Review Form Established protocol

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 Presence of different types of documentation, FHP assessment items, nursing diagnosis, PES format, expected outcomes, nursing interventions; internal linkages between steps of nursing process Presence of information according to demographics and 41 items reecting 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 specicity 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 patients needs, care of terminally ill patient and evaluating nursing care objectives Documentation of the postfall evaluation processes that consists of three concepts: diagnosis, management and monitoring stages of falls management guideline 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 specic 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 patients 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)

An instrument

Content

A structured data collection tool

Content

Voyer et al. (2008) Voutilainen et al. (2004) Wagner et al. (2008) Whyte (2005)

Chart review using a series of measures The Senior Monitor instrument FMAT*

Content and process Content

Content

Audit tool

Structure, process and content

Wong (2009)

Chart audit form

Structure, process and content

Wulf (2000)

Audit form and score sheet

Content

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 & Smedbys comprehensiveness in recording instrument; FHP, Functional Health Patterns; FIS, Fatigue Interview Schedule; FiCND, the Finnish Classication of Nursing Interventions (FiCNI); FiCNI, the Finnish Classication 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 Classication; NOC, Nursing Outcome Classication; 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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part or all of the audit approaches described above. It was common that more than one instrument was used in a study. On the other hand, some instruments such as Ehnfors instrument (Bergh et al. 2007), the Cat-ch-Ing instrument (Bjo rvell et al. 2000) and the Q-DIO instrument (Mu llerStaub et al. 2009) were used in a range of studies. Details about the instruments are summarized in Table 3.

Validation of instruments
Most of the studies reported the criteria generation for the development of the instruments. Development was based primarily on the nursing process model, previous audit instruments, relevant local law and regulations, organizational policies and practice guidelines/protocols/models, focus group interviews with clinical experts, literature review, theoretical frameworks, existing documentation forms and standardized terminologies. The psychometric properties of the instruments were reported with different levels of details in 54 of 77 publications (70%). The general results were as follows. Content validity: in nine studies, content validity of the instruments was formally established (CVI > 080) with a group of experts using a consensus model and focus group approach (Mu ller-Staub et al. 2009). The number of experts ranged from 3 to 20. Face validity: three studies measured face validity by having experts review the instruments and judge their accuracy (Lamond 2000, Eid & Bucknall 2008, Mu ller-Staub et al. 2009). Construct validity: In a study by Paans et al. (2010a), construct validity was assessed on 245 records by explorative factor analysis with principal components and varimax rotation. In Lamonds (2000) study, it was assessed by comparing information obtained in the study with measures identied from previous research to see the correspondence between their varieties of classication schemes. In the study by Larson et al. (2004), factor analysis was performed by 20 auditors on 180 records using principal component analysis for extraction and the varimax orthogonal rotation of the instrument items to determine the interdependencies between observed variables. External validity: in the study by Gjevjon and Helles (2010), external validity was strengthened through the auditor acquiring in-depth knowledge from reading, practising and testing the procedures before initiating the actual study. Criterion-related validity: three instruments were tested for their criterion-related validity using a second instrument having similar objectives to the one being tested to audit a
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proportion of sampled records (Bjo rvell et al. 2000, Moult et al. 2004, Tornvall et al. 2004). Internal consistency: ten publications reported the estimation of internal consistency of the instruments. The resulting Cronbachs Alpha were acceptable as mostly above 070. Inter-rater reliability: forty studies reported the inter-rater reliability of the instruments. This was evaluated through involving two to eight persons to audit the same records independently. One study reported that the inter-rater reliability of the instrument was ensured by using the same researchers (Considine & Potter 2006). The number of records for estimation ranged from 4 to 310. About 10% of total sample was used in eight studies. Inter-rater agreements ranged from 40% to 100%, most were more than 80%. Cohens kappa values were estimated from 037 to 10 with the majority more than 07. In three studies, the inter-rater reliability was estimated by calculating the Spearmans rank correlation coefcient and the values were 078 (P < 0001) in the study by Tornvall et al.s (2009) and 090098 in the study by Larson et al. (2004). Two studies have reported the use of a coding book or user manual and training for the auditors, which might help establish interrater reliability (Junttila et al. 2010, Thoroddsen et al. 2010). Intra-rater reliability was reported in ve studies with varying degrees of agreement, from fair to very good (Larson et al. 2004, Helleso 2006, Mu ller-Staub et al. 2007, 2008a, Wagner et al. 2008). Usability: the usability of the instrument was tested in a the study of Bjo rvell et al. (2000) by three nurses auditing ve records in terms of understanding questions and the phrasing of the instrument. The instrument was revised after this process. In the study of Moult et al. (2004), the instrument was read by parents, volunteers and clinicians to test its usability.

Summary of study ndings

The results of the nursing documentation audit are summarized in two themes: issues of nursing documentation and study interventions and their effects on nursing documentation.

Issues of nursing documentation

This review reveals many shortcomings in nursing documentation. One of the major issues was the lack of documentation concerning a series of nursing care topics. Many studies showed the predominance of documentation of a biomedical nature and insufcient recording of psychological, social, cultural and spiritual aspects of care (Hegarty et al. 2005,
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Altken et al. 2006, Gebru et al. 2007, Gunhardsson et al. 2007, Tornvall et al. 2007). There was also inadequate documentation about assessment of patients preferences and needs for knowledge, previous health behaviour, general health perceptions and quality of life (Cadd et al. 2000, Davis et al. 2000, Laitinen et al. 2010). In addition, patient teaching was rarely evidenced in the records (Karkkainen & Eriksson 2003, Fribeg et al. 2006). A number of studies showed inadequate documentation of the ve steps of the nursing process (Ehrenberg & Birgersson 2003, Bergh et al. 2007, Gjevjon & Helles 2010). In regard to specic care issues, identied deciencies included insufcient documentation of assessment and the rare use of an assessment tool for pain and cognitive impairment (Eid & Bucknall 2008, Hare et al. 2008). Gaps were also found in documentation of assessment, treatment and prevention of pressure ulcers (Gunningberg et al. 2000, Ehrenberg & Birgersson 2003, Baath et al. 2007), assessment of physical characteristics of wound (Gartlan et al. 2010), specic assessment and interventions for older patients with chronic heart failure (Ehrenberg et al. 2004), nursing actions and evaluation for patients in palliative care (Gunhardsson et al. 2007), and assessment of mental ability and interventions to support independent functioning for patients with dementia (Souder & OSullivan 2000, Voutilainen et al. 2004). Additionally, some studies showed a lack of documentation of specic patient data such as vital signs, pupil reaction and mental state, the diagnosis for hospitalization and electrocardiography ECT results. Issues were also found with the use of standardized nursing terminologies. Paans et al. (2010b) found inaccurate documentation of nursing diagnoses and interventions, despite the use of nursing process-based documentation systems. These included lack of PES format with nursing diagnoses, outcome-oriented selection of nursing interventions and incoherence between steps of nursing process. Junttila et al. (2010) identied deciencies in the clinical usability of nursing diagnoses during the intra-operative phase of care. The use of various local diagnostic systems was shown in Karlsens (2007) study. In relation to the structure and process features of nursing documentation, problems included inconsistence in terminologies and timing for documentation (Wong 2009), abstract and unclear recording, inappropriate phrasing of statements (Karlsen 2007); and documenting under a wrong section (Hayrinen & Saranto 2009). Issues identied by Ammenwerth et al. (2001) included incomplete documentation and poor legibility with paper-based documentation and unspecic and too long care plan with electronic records. Importantly, poor concordance between record content and results
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from patient assessment, interviews with patients and nurses and observations of nurses performance (Lamond 2000, Ehrenberg & Ehnfors 2001, Gunningberg & Ehrenberg 2004, Voyer et al. 2008, Marinis et al. 2010) indicated that data documented in the nursing records were not fully adequate and accurate to reect reality.

Study interventions and their effects on nursing documentation

In 25 analytic studies, various study interventions were implemented and their effects were assessed. These interventions included: electronic health record systems (EHRs) (Ammenwerth et al. 2001, Mahler et al. 2007), standardized documentation systems such as the VIPS model (Darmer et al. 2006), a menu-driven incident reporting system (Wagner et al. 2008), standardized nursing languages (Mu ller-Staub et al. 2007), changing ward organization (Hansebo & Kihlgren 2004), nursing process model (Ehrenberg & Ehnfors 2001), ED nursing documentation standards (Considine & Potter 2006), specic nursing care theories (Karkkainen & Eriksson 2005, Aling 2006), education on specic care issues such as postoperative pain (Dalton et al. 2001) and a mixture of some of these interventions. Nursing documentation could be improved to some extent by the study interventions, as shown in most of the study results, although at times no effect or even some negative effects were reported. The implementation of EHRs integrated with standardized structure and language could improve the completeness of common mandatory elds (Helleso 2006), the comprehensiveness of documentation of the nursing process (Larrabee et al. 2001, Daly et al. 2002, Darmer et al. 2006, Gunningberg et al. 2009), the use of standardized languages (Larrabee et al. 2001) and the recording of specic items about particular patient issues (Gunningberg et al. 2009). Improvement was also noted in the relevance of the message (Helleso 2006, Tornvall et al. 2009) and structure and process features of documentation such as dating, signing, abbreviations and symbols (Rykkje 2009, Mahler et al. 2007). Education and organizational support for documentation of the nursing process and the use of standardized nursing languages (NNN) could improve documentation. This helped nurses understand nursing process theory and improve clinical reasoning skills in conducting systematic nursing assessment, formulating accurate nursing diagnoses, planning concrete and effective nursing interventions and documenting observable nursing outcomes (Nilsson & Willman 2000, Bjo rvell et al. 2002, Florin et al. 2005, Mu ller-Staub et al. 2007, 2008b).
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Education was effective in the study by Dalton et al. (2001) about documentation of acute postoperative pain management, but had no obvious effect in Gunningbergs (2004) study about documentation of ulcer prevention. Considine and Potter (2006) showed that a series of written ED standards augmented by an in-service education session could improve initial nursing assessment. Additionally, body mass index tables placed in examination rooms could encourage nurses to document BMI, thus leading to a statistically signicant increase in the diagnosis of obesity (Lemay et al. 2004). In regard to nursing theories, Karkkainen and Eriksson (2005) reported that introducing Erikssons caring theory to the clinical context could improve the recording of the patients experiences and health behaviour. Alings (2006) study showed that introducing ve different nursing theories was associated with the increase in the documentation of nursing history and status upon patients arrival.

Discussion
This review constitutes a cross-sectional survey of nursing documentation audit studies with different designs and study aims. A large number of publications were included. Its strength is that the review provides an overview of current measurement of nursing documentation, from which the denitions, measurement approaches and issues with the quality of nursing documentation can be identied. In addition, the review identies the means by which the quality of nursing documentation could be improved. While conceptually comprehensive, less critical was a limitation of the review. The results of the review were briey presented without describing many details in the original papers. There was no formal appraisal of study quality, so various types of potential bias were not assessed. The review also lacks a critique of nursing documentation audit approaches. The psychometric properties of the audit instruments were generally presented without details about each individual item and without statistical signicance data. This review identies a range of nursing documentation audit instruments. Four instruments were most commonly used in the studies: Ehnfors and Smedbys comprehensiveness-in-recording instrument, the Cat-ch-Ing instrument, the Q-DIO instrument and a protocol including strategies for prevention and treatment of pressure ulcers. The former three were developed in 1993, 2000 and 2007 respectively. They may reect the development of nursing documentation over the past two decades, from the use of a nursing process model to the implementation of standardized nursing documentation systems, then to the application of standardized nursing
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terminologies. The latter was a typical instrument for measuring documented care content in relation to a particular clinical issue. In addition, a special instrument was used to measure the quality of information for patients rather than for communication among health professionals (Moult et al. 2004). These instruments, together with other instruments identied, addressed different aspects of nursing documentation quality. They applied various approaches and reected a complete picture of the quality of nursing documentation as perceived by researchers from different countries. The audit approaches mainly addressed three natural dimensions of nursing documentation: structure or format, process and content, which constitute a complete prole of nursing documentation. Quality structure and format of nursing documentation are essential in ensuring that patients data are presented in a friendly way to facilitate nurses or other health professionals easy access to information essential for clinical decision-making. A proper process of data capture is expected as it enables documentation of valid and reliable information about patients and care. The content of nursing documentation should be the central focus of audit because of its implications for nursing care practice. In sum, nursing care should be fully expressed in the content of the nursing documentation, in a quality structure and format and through an appropriate documentation process. The accuracy of documentation content in relation to patients actual conditions and the care given is an important process feature of documentation quality. If there is no assurance of nursing documentation holding valid and reliable data, there would be no value to discuss its quality. The concordance between documentation content and patient assessment or interviews with nurses and patients can reect the accuracy of data. However, this corroboration of evidence from different sources rather than in situ observation is still an indirect method to approve the accuracy of nursing documentation and has potential bias. The content of nursing documentation, which contains evidence about care, is closely associated with nurses professional expertise. Urquhart et al. (2009) stated that nursing documentation had been used to support different philosophies of nursing practice. While the theoretical knowledge and concepts the nurses have of nursing can be embodied in the written text, the evaluation of nursing documentation should have implications for the advancement of nursing profession. The two basic quality elements, comprehensiveness and appropriateness of nursing documentation, dene how well the content of nursing documentation should be for each step of the nursing process. Important information sources included standardized nursing terminologies, clinical policies or guidelines and standardized nursing
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What is already known about this topic

Quality nursing documentation facilitates better care through enabling effective communication between nurses and other caregivers. Stages in the development of nursing documentation have included the introduction of the nursing process model to the clinical setting, application of electronic documentation systems and the use of standardized nursing languages. Denitions of nursing documentation quality can differ because of variations in practice across countries and settings.

What this paper adds

The paper is a comprehensive review and presents description of nursing documentation audit instruments that have acceptable psychometric properties. Flaws in nursing documentation include lack of documentation on psychological and social aspects of care; insufcient documentation about the steps of the nursing process and lack of specic data in relation to a particular clinical care issue. Approaches to improving nursing documentation include the use of electronic health records, standardized documentation systems, application of specic nursing theories, education and organizational changes.

that nursing care was not fully expressed in the records, so written communication between different caregivers about patients was inadequate. Furthermore, inaccurate formulation of nursing diagnoses and incoherence in documentation of nursing process (Paans et al. 2010b) have reected the nurses lack of knowledge and skill in clinical reasoning and connecting the reasoning process to nursing process. The structure and process of nursing documentation can be improved by the implementation of standardized electronic nursing documentation systems. Approaches such as the implementation of standardized documentation systems with prestructured keywords, standardized nursing terminologies, nursing theories and nursing practice standards or guidelines were shown to help improve the content of nursing documentation.

Conclusion
Nursing documentation has continuously developed with increasing research on the nursing process. In the reviewed studies, the concept of quality of nursing documentation has been operationally dened by various audit instruments, which have focused on different aspects of documentation quality and revealed variations in practices worldwide. All the audit studies use local standards to evaluate local practice. It may not be practical to seek a universal instrument that ts all study settings because of the use of different nursing documentation systems and terminologies based on the local circumstances. However, the underlying factors causing this and its effects on patient outcomes need to be addressed in further research. Several other areas of documentation would also benet from further research. The causes of documentation aws and their effects on patient outcomes need to be investigated. More attention needs to be paid to the concordance between nursing documentation and care delivery on the oor. This is especially important with increasing application of electronic documentation systems in health care with capacity to increase aggregation and the accuracy of data by a more structured and uniform format of data organization. Examination of causes for inaccuracy of data and factors leading to improvement should shed light for better system designs. There is a need to evaluate the quality of audit instruments from conceptual, theoretical and technical perspectives. Conceptual analysis of measurement standards helps to improve understanding of the denition of quality of nursing documentation and to clarify ambiguous concepts and reach precise operational attributes. Theoretical analysis can help determine whether audit standards are relevant to nursing. Critiques of measurement techniques used in audit instru1871

Implications for practice and/or policy

The quality of nursing documentation has multiple dimensions, which can be evaluated by applying various instruments and inuenced by using technological, educational and organizational interventions. Factors leading to varying practice and aws in documentation quality and their effects on nursing practice and patient outcomes need to be further investigated. Attention needs to be paid to the accuracy of nursing documentation in comparison with reality of practice. documentation systems with preformatted items or keywords. These information sources support nurses in documenting nursing process and in making decisions on care-delivery to the patients. They can also generate quality criteria for the evaluation of documentation content. The shortcomings in nursing documentation included deciencies at different levels of the content. This indicated
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ments are essential in determining whether instruments are valid and reliable and can produce strong evidence reecting the quality of nursing documentation. Nursing documentation has come a long way but still has deciencies. Further research and more consistent application of established standards will lead to improvements, with associated benets for practice management and patient outcomes.

Funding
This research is a part of a PhD project supported by Australia Research Council (ARC) industry linkage project LP0882430. Five Australian aged-care organizations: Aged and Community Services Australia, Illawarra Retirement Trust, RSL Care, Uniting Care Ageing South Eastern Region and Warrigal care partially funded the project.

Conict of interest
The authors declare that there is no conict of interest.

Author contributions
NW, DH and PY were responsible for the conceptualization and design of the study. NW collected the data, performed the data analysis and drafted the manuscript. PY reviewed the papers included and the data extraction. DH and PY supervised the study and made intellectual input through critical revisions to the manuscript.

Supporting Information Online

Additional Supporting Information may be found in the online version of this article: Table S1. Characteristics of descriptive studies Table S2. Characteristics of analytic studies Table S3. Auditing instrument and measurement details Please note: Wiley-Blackwell are not responsible for the content or functionality of any supporting materials supported by the authors. Any queries (other than missing material) should be directed to the corresponding author for the article.

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Quality of nursing documentation and audit

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientic journal. JAN contributes to the advancement of evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and theoretical papers. For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan Reasons to publish your work in JAN: High-impact forum: the worlds most cited nursing journal and with an Impact Factor of 1540 ranked 9th of 85 in the 2010 Thomson Reuters Journal Citation Report (Social Science Nursing). JAN has been in the top ten every year for a decade. Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide (including over 6,000 in developing countries with free or low cost access). Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan. Positive publishing experience: rapid double-blind peer review with constructive feedback. Early View: rapid online publication (with doi for referencing) for accepted articles in nal form, and fully citable. Faster print publication than most competitor journals: as quickly as four months after acceptance, rarely longer than seven months. Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library, as well as the option to deposit the article in your own or your funding agencys preferred archive (e.g. PubMed).

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