643189771

REVIEW PAPER

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: [email protected]

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





Ping Yu PhD

Senior Lecturer, Research Director





WANG N., HAILEY D. & YU P. (2011)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. doi: 10.1111/j.1365-2648.2011.05634.x

AbstractAims. This paper reports a review that identified and synthesized nursing

documentation audit studies, with a focus on exploring audit approaches, iden-

tifying audit instruments and describing the quality status of nursing documen-

tation.

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 com-

bination, were used to identify articles published in English between 2000 and

2010.

Review methods. A mixed-method systematic review of quantitative and qualita-

tive studies concerning nursing documentation audit and reports of audit instru-

ment 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 doc-

umentation, 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.

Keywords: audit, evaluation approaches, instruments, nursing documentation,

quality, quality criteria, systematic review

1858 � 2011 Blackwell Publishing Ltd

J A N JOURNAL OF ADVANCED NURSING

Introduction

In modern healthcare organizations, the quality and coor-

dination 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 (Bjorvell 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 informa-

tion 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

(Bjorvell 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 research-

based standardized nursing terminologies such as the Inter-

national Classification of Nursing Practice (ICNP) and the

International Nursing Diagnoses Classification (NANDA

International). Standardized nursing languages provide com-

mon definitions of nursing concepts and allow for theory-

based 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 (Muller-Staub et al. 2007, Thorodd-

sen & 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 lan-

guage becomes essential because a uniform and controlled

vocabulary enables electronic documentation systems to

aggregate data (Ehrenberg et al. 2001, Muller-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 documen-

tation 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 documen-

tation quality, but quality measures were not fully

addressed. Other reviews on nursing documentation have

had different focuses (Muller-Staub et al. 2006, Oroviogoi-

coechea et al. 2008, Urquhart et al. 2009, Jefferies et al.

2010). None of them has concentrated on overall measure-

ment 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 documen-

tation auditing approaches, identifying audit instruments and

JAN: REVIEW PAPER Quality of nursing documentation and audit

� 2011 Blackwell Publishing Ltd 1859

their measurement criteria and describing issues with nursing

documentation identified by auditing.

Design

A mixed-method systematic literature review was conducted,

following the guidelines of the Centre for Reviews and

Dissemination (2008).

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 docu-

mentation’, ‘nursing records’, ‘audit’, ‘evaluation’ and ‘qual-

ity’, 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 paper-

based, electronic, terminologically standardized, prefor-

matted 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.

Search outcome

The titles and abstracts from the primary search were

manually screened by the first 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 finally 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 significance of auditing

approaches to nursing practice.

Data abstraction

Extracted data were placed in an Endnote file. These data

included study aim, design, study intervention, country of

origin, setting, sample size, documentation audit instru-

ment, quality criteria, source of criteria, validation of

instrument, approach of evaluation and key findings 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.

1763 citations identified fromelectronic search, and screened

219 citations identified from 4reviews, and screened

77 publications included

108 publications excluded

185 potentially relevantpublications retrieved forscrutiny

1797 citations excluded

Figure 1 Publication search process.

N. Wang et al.


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 documen-

tation items and number of patient visits. Nursing documen-

tation 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 S1–S3.

Approaches to nursing documentation audit

Nursing documentation was assessed by quantitative and

qualitative content analysis methods, mostly with one or

more formally defined 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).

Different auditing approaches were identified in the study

instruments. These approaches were classified into three

thematic categories, which reflected 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.

Itfocusedondata’sphysicalpresentationssuchasthequantityof

records, completeness, legibility, readability, redundancy and

the use of abbreviations. Twenty studies applied this approach.

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 documen-

tation 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.

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 specifically 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 reflecting

reality. Two quality aspects of documentation content were

assessed in this approach: what documentation has recorded

and how good it is.

What has documentation recorded?

This approach referred to the comprehensiveness of docu-

mentation content. It concerned the presence of data about a

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), stratified and

randomized intervention study (1),

prospective cohort study (1)

Instrument development and

testing reports (7)

Countries of

origin

(number of studies)

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)

Study setting

(number of studies)

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



care process at a general level, without considering its logical

connection to a particular care issue or the patient’s condition.

Issues measured included whether documentation contained

certain types of data such as nursing history, nursing status

(Bjorvell et al. 2002, Gjevjon & Hellesø 2010), baseline data

and discharge summary (Mbabazi & Cassimjee’s 2006);

whether documented nursing care was sufficient to the scope

of care needs defined by the study, such as the Health-Related

Quality of Life (HRQOL) model’s seven dimensions (Davis

et al. 2000); and most commonly, whether information about

the five steps of nursing process was adequately documented

(Ehrenberg & Birgersson 2003, Bjorvell et al. 2002, Mahler

et al. 2007, Thoroddsen et al. 2010, Hayrinen et al. 2010).

How good is nursing documentation content?

This approach addressed the appropriateness of nursing

documentation or documented care at a level specific to a

particular clinical care issue such as pressure ulcers

(Gunningberg et al. 2009) or postoperative pain (Idvall &

Ehrenberg 2002). Documentation content about each step of

the nursing process was measured through seeking data

specifically related to the concerned clinical issue: could be

particular keywords preformatted in a standardized docu-

mentation system (Bergh et al. 2007), variables of clinical

policies or guidelines (Considine & Potter 2006, Junttila

et al. 2010, Gartlan et al. 2010) or standardized terminolo-

gies (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 five phases of the nursing process (Florin et al.

2005, Muller-Staub et al. 2009, Paans et al. 2010b) were also

covered by this approach.

Nursing documentation audit instruments

The majority of papers described the development or use of

nursing documentation auditing instruments, which adopted

Table 2 Quality criteria of nursing documentation

Category Quality criteria

Quality criteria of documentation structure

and format

Completeness, quantity, legibility, appearance, plausibility, patient identification,

abbreviations, correction of error, linguistic correctness (objective or factual language

and scientific 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

Quality criteria of documentation process Signature, date, timeliness, chronological report of events, designation, regularity,

accuracy in comparison with reality and accessibility

Quality criteria of documentation content

• Comprehensiveness of description

of care (or care)

Presence of specific types of documentation (e.g., nursing history and discharge note),

presence of specific variables (e.g., patient’s background information, cause of

admission, address of discharging unit), comprehensiveness of five phases of nursing

process, scope of care (e.g., FHP), presence of information about specific care topics

(e.g., teaching and learning of the patient, emotional and physical support of the

patient or family, patient preference)

• Appropriateness of description

of care (or care)

s Nursing assessment Presence of specific assessment variables in relation to the problem according to

guideline (e.g. grade, size and location and risk assessment for pressure ulcer), use of

specific keywords defined in the system in relation to the problem concerned

(e.g., pedagogically related assessment keywords defined in the VIPS model).

s Nursing problem/diagnosis Adequacy or accuracy of problem statement in accordance with NANDA standardised

terminologies (e.g., PES format), the relevance within PES

s Goal Being clear rather than abstract and vague

s Intervention Presence of particular types of intervention in relation to the nursing problem according

to guidelines (e.g., fluid intake, turning schedule for pressure ulcer), use of specific

keywords defined 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

s Evaluation Presence of NOC (nursing outcome classification) outcomes

s General Internal relationship with five steps of nursing process

N. Wang et al.


Table 3 Nursing documentation audit instruments and measurement details

Reference Instrument Audit

approaches

Measurement details

Bergh et al. (2007) ESCI*

Quantitative and

qualitative keywords

analysis

Content Using five-point scales to measure the comprehensiveness of

documentation of five steps of nursing process

Quantity of documentation of pedagogically related keyword;

presentation in thematic form

Ehrenberg &

Birgersson (2003)

ESCI*

Nominal scale

Content See Bergh et al. (2007)

Documentation of specific signs and symptoms related to leg ulcer

and their accordance with guidelines

Idvall & Ehrenberg

(2002)

ESCI*

Tentative model

NANDA*

characteristics

of acute

pain


Documentation of indicators/categories related to how to conduct

postoperative pain management

Documentation of pain characteristics

Ehrenberg et al.

(2004)

ESCI*

Record audit


Documentation of specific aspects of nursing assessment and

nursing interventions for patients with CHF

Gunningberg &

Ehrenberg (2004)

ESCI*

EPUAP *

Content

and process

See Bergh et al. (2007)

Documentation of patient’s background data, pressure ulcer grade,

size and location, risk assessment and preventive care

Comparing results of documentation audit with results of patient

assessment

Gunningberg

(2004)

ESCI*

Record

audit protocol


Documentation of risk factors, risk assessment, prevention and

treatment of pressure ulcer

Gunningberg et al.

(2009)

ESCI*

EPUAP*


Documentation of patient background data, pressure ulcer grade,

size and location, risk assessment and nursing interventions

Gjevjon & Hellesø

(2010)

Level one VIPS*

categories

Modified ESCI*

Content 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 five-point scales of ESCI*

instrument concerning the five steps of nursing process

Gunningberg et al.

(2000)

Audit protocol

ESCI*

Content Documentation of strategies for prevention and treatment of

pressure ulcers


Gunningberg et al.

(2001)

Audit protocol Content See Gunningberg et al. (2000)

Baath et al.

(2007)

Audit protocol

ESCI*

Content See Gunningberg et al. (2000)


Fribeg et al.

(2006)

Protocol

ESCI*

Content Documentation of patient teaching; patients’ need for knowledge

and nurses’ teaching interventions


Bjorvell et al.

(2000)

Cat-ch-Ing

instrument

Structure, process

and content

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 clarification of

signatures; linguistic correctness and legibility

Bjorvell et al.

(2002)

Cat-ch-Ing

Instrument

Structure, process

and content

See Bjorvell et al. (2000)

Tornvall et al.

(2004)

Cat-ch-Ing

instrument

Structure, process

and content


Tornvall et al.

(2007)

Cat-ch-Ing

audit instrument

Structure, process

and content




Table 3 (Continued)


approaches

Measurement details

Aling (2006) Cat-ch-Ing

instrument

(modified)

Structure and

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

Tornvall et al.

(2009)

Cat-ch-Ing

instrument (part)

Record audit for

clinical issues

Content Audit of date, signatures; clarification 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

Darmer et al.

(2006)

Cat-ch-Ing

instrument

(modified)

Structure, process

and content

The item of nursing discharge note in the Cat-ch-Ing instrument

was excluded; the measurement of nursing diagnosis item was

simplified

Nilsson & Willman

(2000)

Cat-ch-ing

instrument (part)

NoGA instrument*

Structure, process

and content

The first part of the instrument (preliminary?)

Item concerning clarification of signature was excluded. Details

not fully clear

Quantity of the five steps of nursing process

Rykkje

(2009)

Modified Cat-ch-ing

instrument

Structure, process

and content

Adding two items related to the quantity and quality of nursing

transfer note and nursing discharge summary

Hayrinen et al.

(2010)

Modified Cat-ch-Ing

instrument

Quantity of nursing

documentation

Structure, process

and content

See Bjorvell et al. (2000). Adding measure of the use of nursing

classifications (FiCNI and FiCND) and the relationships between

classification

Frequency of the nursing diagnoses, aims for care, nursing

interventions and nursing outcomes

Florin et al. (2005) Cat-ch-Ing instrument

(part)

QOD instrument*

Content Only the quantity and quality variables of nursing diagnosis were

used

Structure and format of diagnostic statement and the relevance in

PES

Larson et al.

(2004)

The Cat-ch-Ing EPI

instrument

Process and

content

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

Muller-Staub et al.

(2009)

Q-DIO instrument* Content 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

Muller-Staub et al.

(2008a)

Q-DIO instrument* Content See Muller-Staub et al. (2009)

Muller-Staub et al.

(2007)

Q-DIO instrument* Content See Muller-Staub et al. (2009)

Muller-Staub et al.

(2008b)

Q-DIO instrument

(part) *

Content See Muller-Staub et al. (2009). The category nursing diagnosis as

process was excluded

Altken et al.

(2006)

3-part medication

audit

instrument

Content Documentation of patient’s demographic information,

medications and detailed data about nurses’ medication

management including assessment, planning care, medication

administration and evaluation of outcomes

Ammenwerth et al.

(2001)

Checklist Structure and

content

Objective quality measurements (e.g. number of stated nursing

aims, completeness) and subjective quality measurements (e.g.

legibility, plausibility, overall quality judgment)

Cadd et al.

(2000)

Proforma Content Documentation of admission assessment about patients’ home

bowel care management and preferences for care

Considine & Potter

(2006)

Standardized

audit tool

Content Documentation of nineteen parameters of initial nursing

assessment, historical variables and primary survey assessment

Davis et al.

(2000)

HRQOL* model Content Documentation of health status in accordance with seven

dimensions of the model

N. Wang et al.


Table 3 (Continued)


approaches

Measurement details

Dalton et al.

(2001)

Audit instrument Content Documentation of items about pain assessment and management:

e.g. pain history, type and intensity, and follow up evaluation

Daly et al.

(2002)

Standardized

instruments

Structure Quantity of nursing diagnosis and nursing interventions

Delaney et al.

(2000)

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

Dochterman et al.

(2005)

NIC* (250/514)

interventions

Content Amount and patterns of NIC* interventions used for patients with

heart failure, hip fracture procedure and risk of falls

Ehrenberg & Ehnf-

ors (2001)

Record audit

protocol

Content and

process

Documentation with regard to the topics such as patient’s

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

Eid & Bucknall

(2008)

PDAT* Content Patient demographic data, diagnosis, co-morbidities, type of

operation, information on pain assessment, management and

education

Ehrenberg et al.

(2001)

Approaches

derived from a

literature review

Structure, process

and content

Formal structure approach (adherence to law and regulations),

process comprehensiveness [ESCI-see Bergh et al. (2007)], and

knowledge based approaches

Ekman &

Ehrenberg

(2002)

FIS* Process and

content

Nominal scale to measure the frequency of 10 characteristics of

fatigue from NANDA*; comparison of audit results with the

results of interviews with patients

Gartlan et al.

(2010)

A paper-based

audit tool

Content Focusing on wound documentation about assessment of clinical

history in relation to the wound and documentation of the

physical characteristics of a wound

Gebru et al.

(2007)

Qualitative content

analysis

Leininger’s Sunrise

Model

Content Identification and coding of entries about patient cultural

background information; quantity of documented data according

to the categories of Sunrise Model

Gregory et al.

(2008)

Documentation audit

tool

Content (structure

and process?)

Compliance to documentation policy (no detailed information

reported), documentation of baseline assessment, episodes of

care, patient’s overall status, ongoing management plan;

objective assessment

Gunhardsson et al.

(2007)

Qualitative and

quantitative

content analysis

Content 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)

Quantitative content

analyses

RAPs*

Intervention guidelines

Structure and

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

Hayrinen & Saranto

(2009)

Narrative content

analysis

Content Quantity, format and accuracy of the documentation of nursing

diagnoses, nursing care aims, nursing interventions (planned/

performed) and nursing outcomes

Hegarty et al. (2005) Quantitative and

qualitative data

analysis

Content 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



Table 3 (Continued)


approaches

Measurement details

Helleso (2006) TWEEAM instrument*

Language functions of

Svennevig’s typologies

Structure and

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

Patient’s Current Status; data of discharge notes

Three language functions (expression, interpersonal and

referential)

Irving et al. (2006) A Focucauldian

approach to discourse

analysis

Structure and

content

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

Junttila et al. (2010) List of nursing

diagnoses in the

PNDS

Content Prevalence of nursing diagnoses listed in the PNDS by

perioperative phases

Junttila et al. (2000) Categorization table Content 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

Karlsen (2007) Critical discourse

analysis

Structure and

content

The nurses’ language expression in assessing patient’s needs,

formulating goals and making a care plan, diagnostic systems and

documentation parlance

Karkkainen &

Eriksson (2003)

Lukander’s Nursing

Audit instrument

Content 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

Karkkainen &

Eriksson (2005)

Lukander’s Nursing

Audit instrument

Content See Karkkainen & Eriksson (2003)

Lemay et al.

(2004)

Abstraction tool Content Documentation of BMI calculation, an obesity diagnosis, and

inclusion of heights and current weights

Lamond (2000) Coding scheme of

MSA*

Content and

process

Documentation of comprehensiveness variables concerning patient

assessment; concordance of information between the patient

notes and the nurse shift report

Lunney (2006) NNN* Content Documentation of NANDA diagnoses, diagnoses relating to health

promotion, NIC* interventions and NOC* outcomes

Lagerin et al.

(2007)

Checklist Content Documentation of VIPS keywords covering 10 key areas of leg

ulcer care and treatment

Laitinen et al.

(2010)

Strauss and Corbin’s

paradigm model

Content Concepts obtained through a series of qualitative data analysis

steps were organized into four components of the paradigm

model: conditions, interaction, emotions and consequences

Larrabee et al.

(2001)

NCPDCI* Structure and

content

Documentation of nurse assessments of patient outcomes

(NASSESS), achievement of patient outcomes (NGOAL), nursing

interventions done (NQUAL) and routine assessment (e.g. vital

signs)

Mahler et al.

(2007)

Quantitative and

qualitative checklist

Structure, process

and content

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

Marinis et al.

(2010)

Checklists Content and process Consistency between recorded and observed nursing assessment

activities and interventions

Mbabazi &

Cassimjee

(2006)

3-section quality

measurement

checklist

Structure, process

and content

Documentation of baseline data, diagnosis, treatments,

evaluations and discharge summary; regularity of vital sign

measurement, use of scientific terms and chronological report of

events

N. Wang et al.


Table 3 (Continued)


approaches

Measurement details

Moult et al.

(2004)

EQIP* Structure, process

and content

Using yes/no and a 4-point scale to measure the completeness,

appearance, understandability and usefulness of documented

information for patients

Paans et al.

(2010a)

D-Catch instrument Structure, process

and content

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

Paans et al.

(2010b)

D-Catch instrument Structure, process

and content

See Paans et al. (2010a)

Souder &

O’Sullivan

(2000)

Chart Review Form

Established protocol

Content Documentation of impaired cognitive status

Patient assessment using several brief screening measures of

cognitive status

Agreement of different measures was addressed

Thoroddsen &

Ehnfors

(2007)

An instrument Content Presence of different types of documentation, FHP assessment

items, nursing diagnosis, PES format, expected outcomes, nursing

interventions; internal linkages between steps of nursing process

Thoroddsen et al.

(2010)

A structured data

collection tool

Content Presence of information according to demographics and 41 items

reflecting nursing assessment, nursing diagnosis, signs and

symptoms, aetiologies, care plan (goal and nursing interventions)

and progress notes

Voyer et al.

(2008)

Chart review using a

series of measures

Content and

process

Accuracy of the documentation of delirium symptoms, namely the

sensitivity and specificity of the nursing notes, in comparison with

results of patient assessment by using CAM

Voutilainen et al.

(2004)

The Senior Monitor

instrument

Content Documentation in accordance to criteria under seven sections such

as planning nursing care, meeting the patient’s needs, care of

terminally ill patient and evaluating nursing care objectives

Wagner et al.

(2008)

FMAT* Content Documentation of the postfall evaluation processes that consists of

three concepts: diagnosis, management and monitoring stages of

falls management guideline

Whyte

(2005)

Audit tool Structure, process

and content

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

Wong

(2009)

Chart audit form Structure, process

and content

Documentation of specific 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 patient’s

bedside assessment and interviews with nurses of provided care

Wulf

(2000)

Audit form and score

sheet

Content 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)

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 & Smedby’s comprehensiveness in recording instrument;

FHP, Functional Health Patterns; FIS, Fatigue Interview Schedule; FiCND, the Finnish Classification of Nursing Interventions (FiCNI); FiCNI,

the Finnish Classification 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 Classification; NOC, Nursing Outcome Classification; NNN, NANDA

Diagnosis, NIC and NOC; NoGA, not reported, PDAT, The Pain Documentation Audit tool; PES, problem, aetiologies and signs and symp-

toms; 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.



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

(Bjorvell et al. 2000) and the Q-DIO instrument (Muller-

Staub 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 > 0Æ80) with a

group of experts using a consensus model and focus

group approach (Muller-Staub et al. 2009). The number of

experts ranged from 3 to 20.

• Face validity: three studies measured face validity by hav-

ing experts review the instruments and judge their accuracy

(Lamond 2000, Eid & Bucknall 2008, Muller-Staub et al.

2009).

• Construct validity: In a study by Paans et al. (2010a),

construct validity was assessed on 245 records by explor-

ative factor analysis with principal components and

varimax rotation. In Lamond’s (2000) study, it was assessed

by comparing information obtained in the study with

measures identified from previous research to see the

correspondence between their varieties of classification

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 Hellesø

(2010), external validity was strengthened through the

auditor acquiring in-depth knowledge from reading, prac-

tising 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

proportion of sampled records (Bjorvell et al. 2000, Moult

et al. 2004, Tornvall et al. 2004).

• Internal consistency: ten publications reported the estima-

tion of internal consistency of the instruments. The resulting

Cronbach’s Alpha were acceptable as mostly above 0Æ70.

• 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 agree-

ments ranged from 40% to 100%, most were more than

80%. Cohen’s kappa values were estimated from 0Æ37 to

1Æ0 with the majority more than 0Æ7. In three studies, the

inter-rater reliability was estimated by calculating the

Spearman’s rank correlation coefficient and the values were

0Æ78 (P < 0Æ001) in the study by Tornvall et al.’s (2009)

and 0Æ90–0Æ98 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 five studies with

varying degrees of agreement, from fair to very good

(Larson et al. 2004, Helleso 2006, Muller-Staub et al.

2007, 2008a, Wagner et al. 2008).

• Usability: the usability of the instrument was tested in a the

study of Bjorvell et al. (2000) by three nurses auditing five

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 findings

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 documen-

tation. One of the major issues was the lack of documenta-

tion concerning a series of nursing care topics. Many studies

showed the predominance of documentation of a biomedical

nature and insufficient recording of psychological, social,

cultural and spiritual aspects of care (Hegarty et al. 2005,

N. Wang et al.


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 five steps of the nursing process (Ehrenberg & Birgersson

2003, Bergh et al. 2007, Gjevjon & Hellesø 2010). In regard

to specific care issues, identified deficiencies included insuf-

ficient 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), specific

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 & O’Sullivan 2000, Voutilainen et al. 2004). Addi-

tionally, some studies showed a lack of documentation of

specific patient data such as vital signs, pupil reaction and

mental state, the diagnosis for hospitalization and electro-

cardiography ECT results.

Issues were also found with the use of standardized nursing

terminologies. Paans et al. (2010b) found inaccurate docu-

mentation of nursing diagnoses and interventions, despite the

use of nursing process-based documentation systems. These

included lack of PES format with nursing diagnoses, out-

come-oriented selection of nursing interventions and inco-

herence between steps of nursing process. Junttila et al.

(2010) identified deficiencies in the clinical usability of

nursing diagnoses during the intra-operative phase of care.

The use of various local diagnostic systems was shown in

Karlsen’s (2007) study.

In relation to the structure and process features of nursing

documentation, problems included inconsistence in terminol-

ogies 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 identified by Ammenw-

erth et al. (2001) included incomplete documentation and

poor legibility with paper-based documentation and unspe-

cific and too long care plan with electronic records. Impor-

tantly, poor concordance between record content and results

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 reflect reality.

Study interventions and their effects on nursing

documentation

In 25 analytic studies, various study interventions were

implemented and their effects were assessed. These interven-

tions 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 (Muller-Staub et al.

2007), changing ward organization (Hansebo & Kihlgren

2004), nursing process model (Ehrenberg & Ehnfors 2001),

ED nursing documentation standards (Considine & Potter

2006), specific nursing care theories (Karkkainen & Eriksson

2005, Aling 2006), education on specific 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 inte-

grated with standardized structure and language could

improve the completeness of common mandatory fields

(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 specific 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,

Bjorvell et al. 2002, Florin et al. 2005, Muller-Staub et al.

2007, 2008b).



Education was effective in the study by Dalton et al. (2001)

about documentation of acute postoperative pain manage-

ment, but had no obvious effect in Gunningberg’s (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 significant increase in the diagnosis of obesity

(Lemay et al. 2004).

In regard to nursing theories, Karkkainen and Eriksson

(2005) reported that introducing Eriksson’s caring theory to

the clinical context could improve the recording of the

patient’s experiences and health behaviour. Aling’s (2006)

study showed that introducing five 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

definitions, measurement approaches and issues with the

quality of nursing documentation can be identified. In

addition, the review identifies 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

briefly 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 significance data.

This review identifies a range of nursing documentation

audit instruments. Four instruments were most commonly

used in the studies: Ehnfors and Smedby’s comprehensive-

ness-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 reflect the development of nursing documentation over

the past two decades, from the use of a nursing process model

to the implementation of standardized nursing documenta-

tion systems, then to the application of standardized nursing

terminologies. The latter was a typical instrument for

measuring documented care content in relation to a partic-

ular 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

identified, addressed different aspects of nursing documenta-

tion quality. They applied various approaches and reflected 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 profile 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 essen-

tial 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 reflect 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 documen-

tation, define how well the content of nursing documentation

should be for each step of the nursing process. Important

information sources included standardized nursing terminol-

ogies, clinical policies or guidelines and standardized nursing

N. Wang et al.


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

deficiencies at different levels of the content. This indicated

that nursing care was not fully expressed in the records, so

written communication between different caregivers about

patients was inadequate. Furthermore, inaccurate formula-

tion of nursing diagnoses and incoherence in documentation

of nursing process (Paans et al. 2010b) have reflected 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 docu-

mentation.

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 defined 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 fits 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 benefit

from further research. The causes of documentation flaws

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 floor. 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. Exam-

ination 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 definition 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 instru-

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.

• Definitions 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; insufficient documentation about the steps of the

nursing process and lack of specific 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

specific nursing theories, education and organizational

changes.

Implications for practice and/or policy

• The quality of nursing documentation has multiple

dimensions, which can be evaluated by applying various

instruments and influenced by using technological,

educational and organizational interventions.

• Factors leading to varying practice and flaws 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.



ments are essential in determining whether instruments are

valid and reliable and can produce strong evidence reflecting

the quality of nursing documentation.

Nursing documentation has come a long way but still has

deficiencies. Further research and more consistent application

of established standards will lead to improvements, with

associated benefits 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.

Conflict of interest

The authors declare that there is no conflict 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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N. Wang et al.


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