Objective: This paper is to share the experience of developing approaches in measuring the quality of nursing documentation in residential aged care homes.
Background: The quality of care depends on access to quality nursing documentation which ensures continuity and individuality of nursing care. Electronic nursing documentation systems are anticipated to increase caregivers’ access to more accurate, adequate and up-to-date data. Evaluation of the quality of nursing documentation calls for quality research and valid instruments with comprehensive and universal criteria. A preliminary nursing documentation audit instrument has been developed for a research project aimed at evaluating the quality of electronic versus paper-based nursing documentation to determine the effect of electronic nursing documentation systems on the quality of nursing documentation in aged care homes.
Methods: Three sources of information were reviewed to explore the approaches to measure the quality of nursing documentation: a comprehensive literature review, relevant Australian legal and professional requirements, and organisational nursing documentation practice.
Results: Firstly, approaches suggested by the literature mainly focused on three elements of nursing documentation: nursing process, quality of recording, and completeness and comprehensiveness of information. Review of the nursing process measured the quality of nursing care as evidenced in the nursing records and focused on the content of the nursing records to see how nursing care was delivered in conformance with the five phases of the nursing process. Both quantitative and qualitative methods were applied for nursing process review: quantitative method examined the presence of each phase of nursing process; whereas qualitative method concerned the internal relationship between them. Quality of recording concerned the mechanical process of recording as its adherence to legal requirements. Completeness referred to the extent to which the items in a nursing document were filled in. Comprehensiveness referred to the scope of care evidenced in the nursing records against established coverage of care needs. Secondly, Australia’s legal and professional guidelines and requirements for standards for nursing documentation were considered as an essential source to derive quality criteria for the documentation audit instrument. Nursing process, resident and family involvement and quality of recording are the focus of those requirements. Thirdly, review of partner organizational nursing documentation practice has found consistent requirements which confirmed the quality criteria derived from legal and professional guidelines. A preliminary nursing documentation audit instrument has been constructed with a list of questions against those quality criteria. An initial consultation with eight nurses has been undertaken for the content validity of the instrument. The instrument will be further tested for its feasibility, reliability, and validity through a pilot study and consultation with more nurses. Examples of the instrument questions were presented in the paper.
Conclusion: A mixture of approaches that draws on published studies, local requirements and clinical experience has been used to develop an initial version of an audit instrument.