|Groot, K. de, Triemstra, M., Paans, W., Francke, A.L.|
Quality criteria for nursing documentation: a systematic meta-review of systematic reviews.
In: Abstractbook: The 17th European Doctoral Conference in Nursing Science. 22-23 june 2018 in Maatstricht. p. 39-40.
Nursing documentation is vital for the patient’s safety and the quality of nursing care. However, in nursing practice the quality of documentation is moderate to poor and there is uncertainty which criteria have to be met to ensure high-quality nursing documentation. An overview of evidence-based relevant quality criteria is lacking.
Aim of the study
To obtain an overview of existing evidence regarding quality criteria for nursing documentation.
We systematically searched the databases Pubmed and CINAHL by using combinations of the following terms: nursing, handoffs, records, documentation, quality, indicators and accuracy. Eligible for inclusion were systematic reviews addressing quality criteria for nursing documentation, published between 2010 and April 2017. The selection process was done independently by two authors. The methodological quality of the reviews was assessed with the AMSTAR tool. A narrative synthesis was conducted using a extraction format.
The search yielded 3088 potentially relevant references, including 11 systematic reviews that met the inclusion criteria. No clearly defined quality indicators were found in the selected reviews. Nevertheless, several quality criteria were described referring to the importance of alignment with the nursing process and the use of standard nursing terminologies. Furthermore, electronic documentation is preferred to paper documentation.
Discussion / conclusion
The pursuit of high-quality nursing documentation in nursing practice is challenged by the lack of evidence-based quality indicators, although several quality criteria exist. Evidence-based quality criteria are: nursing documentation in line with the nursing process, and using standardized nursing terminologies.
Practical or academic relevance
Because of the lack of quality indicators there is hardly any evidence on the effect of nursing documentation on the quality of nursing care and patient’s safety. Future research should focus on the development of quality indicators with clear norms for nursing documentation, using a phased approach. (aut. ref.)