Kim De Groot1,2, Mattanja Triemstra1, Wolter Paans3, Anneke L Francke1,4. 1. Netherlands Institute for Health Services Research (Nivel), Utrecht, The Netherlands. 2. Thebe Wijkverpleging [Home care organisation], Tilburg, The Netherlands. 3. Research Group Nursing Diagnostics, Hanze University of Applied Sciences, Groningen, The Netherlands. 4. Department of Public and Occupational Health, Amsterdam Public Health research institute/VU Medical Centre, Amsterdam, The Netherlands.
Abstract
AIM: To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation. DESIGN: Systematic review of systematic reviews. DATA SOURCES: We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches. REVIEW METHODS: Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis. RESULTS: Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff. CONCLUSION: 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. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation. IMPACT: There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.
AIM: To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation. DESIGN: Systematic review of systematic reviews. DATA SOURCES: We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches. REVIEW METHODS: Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis. RESULTS: Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff. CONCLUSION: 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. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation. IMPACT: There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.
Authors: Tanja Moilanen; Mari Sivonen; Kirsi Hipp; Hanna Kallio; Oili Papinaho; Minna Stolt; Riitta Turjamaa; Arja Häggman-Laitila; Mari Kangasniemi Journal: Glob Qual Nurs Res Date: 2022-07-07