Developing measurements of the quality of electronic versus paper-based nursing documentation in Australian aged care homes

Objective: To discuss the experience of developing approaches to measuring the quality of nursing documentation in residential aged care homes. Methods: Three information sources were reviewed to explore approaches in auditing nursing documentation: the current literature, relevant Australian legislative and professional requirements, and organizational nursing documentation practice. Results: Approaches suggested by the literature were mainly focused on three dimensions of nursing documentation: structure and format, process and content. The detailed standards of nursing documentation have been identified by reviewing the relevant Australian legislative and professional requirements and recommendations, and organizational nursing documentation practice. A nursing documentation audit instrument has been constructed, using relevant quality criteria derived from the three information sources. Face validation and content validation of the instrument were conducted. The validity of the instrument was established, with a high level of consensus among aged care staff. The instrument is being tested to verify its applicability and reliability through a pilot study. Conclusion: A systematic document analysis on published studies, local legislative and professional requirements and aged care organizational nursing documentation practice has been conducted to develop a validated nursing documentation audit instrument. It is anticipated that the instrument will not only serve the purpose of collecting data for a research project, but also be useful as an auditing tool for nursing documentation in Australian residential aged care facilities.