Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review.

  title={Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review.},
  author={Ning Wang and David Hailey and Robert Yu},
  journal={Journal of advanced nursing},
  volume={67 9},
AIMS This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation. [] Key MethodDATA 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.

Figures and Tables from this paper

Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews.

Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important for high-quality nursing documentation.

Improving the quality of nursing documentation in a palliative care setting: a quality improvement initiative.

A quality-improvement project to develop nursing documentation that reflects holistic care within a specialist palliative centre has enabled the consistent documentation of holistic nursing care and patients' perspectives, but continuous education is necessary to sustain positive results and ensure that documentation does not become a 'tick box' exercise.

Nursing Documentation Study at Teaching Hospital in KSA

The study aimed to examine the current practice of nursing care documentation and develop project for improvement and recommend to nursing administration to use a multidisciplinary approach to develop policies and guidelines on nursing documentation.

Impacts of structuring nursing records: a systematic review.

The value of standardised nursing language (SNL) is proven by its support of daily workflow, delivery of nursing care and data reuse, thus contributing to patient safety.


Studying nurses’ experiences of documentation can help acquire a deep understanding about documentation-related challenges and develop strategies for promoting documentation and the gap between realities and documentations diminishes the value of documentations.

Impact of Electronic Nursing Documentation ( End ) In Terms Of Quality of Nursing Documentation

As the use of technology becomes imminent in the healthcare sector, it is imperative that nurses in addition to providing quality care develop, implement and embrace informatics in order to effortlessly adapt to the impending transition.

The Accuracy of Documented Nursing Care Plan among Registered Nurses

Nursing documentations is inaccurate, lacking precision, and low in quality, according to a nationwide study conducted using electronic databases.

An evaluative audit of the introduction of a new nursing document within a specialist palliative care inpatient unit in Ireland

This project evaluated a new palliative nursing documentation system and identified that utilizing a structured document promoted accurate recording of clinical information and limits inconsistent documentation.

Evaluation of vocal-electronic nursing documentation: A comparison study in Iran

Vocal-electronic systems help to improve quality of nursing documentation, suggesting this aspect may be essential to implementing a successful system in local settings.



Evaluating nursing documentation - research designs and methods: systematic review.

The use of structured nursing terminology in electronic patient record systems will extend the scope of documentation research from assessing the quality of documentation to measuring patient outcomes.

Nursing diagnoses, interventions and outcomes - application and impact on nursing practice: systematic review.

Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained, which reveals deficits in reporting of signs/symptoms and aetiology.

Discursive practices in the documentation of patient assessments.

Nursing documentation is viewed as a social practice and a conduit through which particular power effects are produced and reproduced, rather than simply a matter of, for example, knowledge, individual choice or good practice.

Effects of a Computer-based Nursing Documentation System on the Quality of Nursing Documentation

Whether the introduction of a computer based nursing documentation system can improve documentation quality on 4 wards of the University Medical Center Heidelberg over a period of 18 months is examined.

Patient-focused nursing documentation expressed by nurses.

This study found that the nursing documentation was patient-focused, to some extent, which is significant because nursing documentation represents much more than simply a record of the continuity of care.

Development of an audit instrument for nursing care plans in the patient record

The Cat-ch-Ing instrument has proved to be a valid and reliable audit instrument for nursing records when the VIPS model is used as the basis of the documentation.

Prevalence of accurate nursing documentation in patient records.

Effective documentation systems that support nurses in linking diagnoses, interventions and progress and outcome evaluations could be helpful and support the development of universal criteria for accurate nursing documentation.

Auditing nursing content in patient records.

The results of this study suggest that audits of patient records should not be solely limited to encompass the formal structure of recording, and suggest the process comprehensiveness approach in combination with a critical review of the knowledge base for the assessment, diagnosis and interventions of patients records.

Electronic nursing documentation in primary health care.

Limits in the nursing documentation were demonstrated that inhibited the possibility of using it to evaluate the care given and there is a need for support and education to strengthen the district nurses' professional identity.