Evaluating nursing documentation – research designs and methods: systematic review

Title.  Evaluating nursing documentation – research designs and methods: systematic review.
Aim.  This paper is a report of a review conducted to assess the research methods applied in the evaluation of nursing documentation.
Data sources.  The material was drawn from three databases: CINAHL, PubMed and Cochrane using the keywords nursing documentation , nursing care plan , nursing record system , evaluation and assessment . The search was confined to relevant electronically-retrievable studies published in the English language from 2000 to 2007. This yielded 41 studies, including two reviews.
Methods.  Content analysis produced a classification into three themes: nursing documentation, patient-centred documentation and standardized documentation. Each study was assessed according to its research design, methodology, sample size and focus of data collection. In addition, the studies categorized under the heading of standardized documentation were assessed in terms of their outcomes.
Results.  Most of the studies ( n  = 19) focused on patient-centred documentation. Most ( n  = 20) were retrospective studies and used data collected from patient records ( n  = 35). An audit instrument was used to assess nursing documentation in almost all the studies. Studies classified under the heading of standardized documentation showed more positive than negative effects with respect to quality, the nursing process and terminology use, knowledge level and acceptance of computer use in documentation.
Conclusion.  The use of structured nursing terminology in electronic patient record systems will extend the scope of documentation research from assessing the quality of documentation to measuring patient outcomes. More data should also be collected from patients and family members when evaluating nursing documentation.