Evaluating nursing documentation - research designs and methods: systematic review.

Area of Science:

• Nursing Research
• Health Informatics
• Documentation Systems

Background:

• Evaluating nursing documentation is crucial for quality patient care.
• Research methods in this area have evolved significantly.
• Understanding current evaluation techniques informs future research.

Purpose of the Study:

• To systematically review and assess research methodologies used in evaluating nursing documentation.
• To classify studies based on documentation type (patient-centred, standardized).
• To analyze the research designs and data collection methods employed.

Main Methods:

• A comprehensive literature search was conducted across CINAHL, PubMed, and Cochrane databases (2000-2007).
• Keywords included nursing documentation, care plans, record systems, evaluation, and assessment.
• Content analysis classified 41 studies into themes, assessing research design, methodology, and outcomes.

Main Results:

• Most studies (n=19) focused on patient-centred documentation; the majority (n=20) were retrospective, using patient records (n=35).
• Audit instruments were commonly used.
• Standardized documentation studies reported more positive effects on quality, nursing process, terminology, and computer use acceptance.

Conclusions:

• Structured nursing terminology in electronic records can shift research focus from documentation quality to patient outcomes.
• Future research should incorporate patient and family perspectives.
• Standardized documentation shows promise for improving care quality and informatics integration.