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

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.

Keywords: nurse; nursing documentation; nursing process; nursing terminologies; systematic review.