TY - JOUR
T1 - 护理文件质量标准、工具和要求:对系统评价进行系统综述
T2 - A systematic review of systematic reviews
AU - de Groot, Kim
AU - Triemstra, Mattanja
AU - Paans, Wolter
AU - Francke, Anneke L.
N1 - Funding Information: This research was funded by ZonMw, the Netherlands Organisation for Health Research and Development (programme Quality Standards). The funder had no role in conducting this research. Publisher Copyright: © 2018 John Wiley & Sons Ltd Copyright: Copyright 2019 Elsevier B.V., All rights reserved.
PY - 2019/7/1
Y1 - 2019/7/1
N2 - 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.
AB - 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.
KW - nurse
KW - nursing documentation
KW - nursing process
KW - nursing terminologies
KW - systematic review
UR - http://www.scopus.com/inward/record.url?scp=85060146459&partnerID=8YFLogxK
U2 - https://doi.org/10.1111/jan.13919
DO - https://doi.org/10.1111/jan.13919
M3 - Review article
C2 - 30507044
SN - 0309-2402
VL - 75
SP - 1379
EP - 1393
JO - Journal of advanced nursing
JF - Journal of advanced nursing
IS - 7
ER -