Objective: This paper is to share the experience of developing approaches in measuring the quality of nursing documentation in residential 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 organizational 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. Secondly, Australia’s legal and professional guidelines and standards for nursing documentation have provided detailed requirements on nursing documentation, which concern nursing process, resident and family involvement and quality of recording. Thirdly, review of partner organizational nursing documentation practice has found consistent requirements which confirmed the quality criteria derived from legal and professional guidelines. A 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 consultations 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.
Electronic Nursing Documentation; Paper-based Nursing Documentation; Quality; Nursing Documentation Audit Instrument; Aged Care