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

Groot, K. de, Triemstra, M., Paans, W., Francke, A.L. Quality criteria, instruments and requirements for nursing documentation: a systematic review of systematic reviews. Journal of Advanced Nursing: 2019(7), 1379-1393
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Aim
To obtain an overview of existing evidence regarding 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 pre‐defined 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.