The Nursing and Midwifery Content Audit

Methods

opportunity to collect verbatim nursing notes from nurses and midwives within the NMCAT.

A mixed methods design was used in this study Likert-scale approaches have also been used to

including a concurrent health record audit examining determine improvements in the quality of nursing doc-

the criteria for nursing documentation (derived from the umentation (Muller-Staub et al. 2007). These authors

standards) and use of text from notes as examples of the used a 29-item four-point likert scale tool known as the

criteria reflecting the qualitative aspects of the study. Quality of Nursing Diagnosis, Interventions and Out- comes (Q-DIO) to detect changes in the quality of

Sample and setting

documentation after an education intervention. Using a pre-post test design, Muller-Staub et al. (2007) identi-

A total of 200 records from 10 metropolitan hospitals fied improvements after educational interventions. The

formed the data. Twenty records were randomly criteria within the NMCAT did not lend themselves to a

selected using random number tables from wards likert-scale approach, although we acknowledge the

identified from hospitals participating in the present usefulness of a continuous data set of this kind.

study. Data were pooled to develop benchmarks for the health service, while individual hospitals received reports on their 20 records examined, with a copy of the

Design aspects NMCAT and explanatory notes (Appendix I). The

Audit tools should provide data in a timely manner, inter-rater reliability testing examined the agreement or therefore allowing clinicians and managers to imple-

disagreement between two raters. ment changes in response to the findings (Anderson et al. 2009). The tool proposed here needed to be short

NMCAT tool

and focused on the standards developed. The audit needed to be conducted within 5–10 minutes in most

The NMCAT includes three major sections. Section 1 is cases. The ideal was the nurse managers or nursing

completed on most records (9 out of 10 records) and peers could undertake an audit of 20 records every

addresses the criteria outlined in Table 1 (see Appen- 3–6 months (within 1–2 hours), generate the findings to

dix I). Sections 2 and 3 (see Appendix I) are completed share with staff and put in place strategies to address

on every 10th record and provide important text for

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

M. Johnson et al.

demonstrating where areas of strengths and weakness These changes included adding more specific wording occur. The survey tool was developed within Survey

and removing response categories that did not reflect the experience e.g. it was not felt that having a present and

system. The response categories ranged from absent, always present category for education was reasonable present, always present and not rated. Explanatory

so these categories were collapsed into present only. notes for each of the response categories for the criteria

The time sampling approach was appropriate as can are presented in Appendix I.

be seen from the distribution of records across the The NMCAT uses a time sampling approach and

expected length of stay of patients within the health allows for capture of records covering five major time

facilities (see Table 3). The mean time for completion of periods: admission to 24 hours, between 25 and

an audit was 6.64 minutes (4.25 minutes SD).

48 hours after admission, 49 and 72 hours after admission, 73 and 96 hours after admission, prior to

discharge and other cases of extended periods. The Table 2

Inter-rater reliability

auditor was required to locate three nursing entries (or a 24-hours time period). The large sample size ensured a

Per cent agreement

distribution across the usual time periods for inpatients.

Time 1 Time 2

Criteria

n = 10 (%) n = 10 (%)

60 Procedure 70

The patientÕs problem was written

in terms of what the patient

The Director of Nursing and Midwifery Services

actually said or what was observed by the nurse

(DON&MS) from each hospital participating in the

There was an entry recording

study was requested to nominate a ward for the docu-

the status of the patient, whether

mentation audit. One of the authors collected the data

changed or unchanged, on each shift Any change in the patientÕs

60 and was generally well supported by staff within the unit. 80

status was indicated and objective

Data entry was done directly into the dedicated Survey

information documented

Monkey URL where access to the internet was available.

The observation, a sign or a

In most cases, these data were placed on a hard copy form symptom, was written in terms of

what the nurse observed and

of the survey and later entered into Survey Monkey URL.

was not based on the nurseÕs

Although the records were examined by one data col-

assumptions about the patient The action taken by a nurse

50 lector, inter-rater reliability testing was also undertaken. 80

when finding a change in the patientÕs

Data were analysed within the health service nursing

status is recorded

research centre and results were then sent directly to the

The patientÕs response to

ward areas and the DON&MS. Aggregated data from

treatment was stated The patientÕs response to

60 all services were presented in a summary report with 80

medication was stated

recommendations to the Area DON&MS and all

The nursing documentation was

DON&MS and this provided the benchmarks for pre-

a chronological report of events

implementation of the standards. that described the patientÕs experience

from admission to discharge

Ethical approval was sought and obtained from two

All entries in the nursing

Health and Research Ethics Committees covering all the

documentation were legible

hospitals participating in the study.

There was a recorded time and

date on every entry in the nursing documentation

30 Results 100

Entries were written as incidents occurred

Entries were written in a logical

Inter-rater reliability was confirmed on Time 2 with and sequential manner

Entries in documentation appear uniquely 40 90

most criteria achieving at least 70% agreement between

The education and/or psychosocial

the raters (see Table 2). The last criterion relating to

care provided by nurses is

psychosocial care and education was further defined to recorded in the notes reflect education that would be expected to be received

The 20 mock records were created by clinicians and researchers and

relating to the condition. Nonetheless, the overall

contained three nursing note entries reflecting a 24 hour period. The

agreement was 81% or 85% excluding the education

cases included medical-surgical patient scenarios, mental health scenarios, paediatric clinical cases, and midwifery cases. After

criterion. Modifications to the criteria were undertaken

modification of the categories relating to education 85% agreement

after Time 1 reliability results were received.

was achieved.

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

10-minute nursing documentation audit tool

Table 3

present). Documentation by variance was demonstrated

Time period covered in the audit

with most records reflecting abnormal rather than

Time

No. (%)

normal vital signs or other observations. The criterion

requiring that the patientÕs name be used is a new cri-

Between 0 and 24 hours of admission

Between 25 and 48 hours of admission

terion for staff in hospitals participating in the present

Between 49 and 72 hours of admission

study and was accordingly infrequently recorded

Between 73 and 96 hours of admission

(11%). The purpose of this criterion is to personalize

Prior to discharge

the records for the patient and nurse and allow the

Total

subject of the documentation to be the patient rather than a list of nursing tasks disconnected from the patient which was frequently found.

Achieving standards and meeting criteria relating to the content of nursing notes

Legal requirements of nursing documentation Recording the patientÕs status whether changed or un-

changed at every shift was found in most records (92% The achievement of legal requirements has been the focus present or always present) (see Table 4). Similarly, the

of nursing audits in hospitals participating in the present use of objective information when reporting changes

study in the past. Most of these criteria were met to a high was apparent (what the patient said or objective signs).

level (85% or more) (see Table 5). However, the use of Patient responses to treatment was found in most

varying abbreviations (81%), many of which were not on records, although the patient responses to medication

the official list for the organization, was a substantial was not as extensive (63.5% present and always pres-

problem.

ent). The record did represent a chronological record of As the NMCAT also captured text from the record the patientÕs hospital stay, although the presence of

the following examples are presented to highlight when contemporaneously reporting (or the recording of

the various criteria within the NMCAT were met or not events immediately after they occur) was not wide-

met and further demonstrate both the Standards and the spread in the records (41.66% present and always

NMCAT criteria in use.

Table 4 Nursing and Midwifery Content Audit Tool (NMCAT) criteria and achievement of criteria prior to implementation (n = 200)

Always present Not rated Criterion relating to content of nursing documentation

Absent no.

Sometimes

no. (%) no. (%) The patientÕs problem was written in terms of what the patient

No.

present no. (%)

168 (84.0) actually said or what was observed by the nurse There was an entry recording the status of the patient, whether

133 (68.55) 6 changed or unchanged, on each shift Any change in the patientÕs status was indicated and objective

120 (75.47) 49 information documented The observation, a sign or a symptom, was written in terms of what

154 (79.79) 7 the nurse observed and was not based on the nurseÕs assumptions about the patient

75* (56.81) 68 The patientÕs response to medication was stated

The patientÕs response to treatment was stated

29* (34.11) 115 The nursing documentation was a chronological report of events

171 (91.93) 14 that described the patientÕs experience from admission to discharge All entries in the nursing documentation were legible

132 (66.0) There was a recorded time and date on every entry in the

122 (61.0) nursing documentation Entries were written as incidents occurred

27* (14.06) 8 Entries were written in a logical and sequential manner

173 (92.51) 13 Entries in documentation appear uniquely

152 (76.76) 2 The education and/or psychosocial care provided by nurses is

0* (0.0) 177 recorded in the notes The nurse refers to the patient by name in the nursing

4* (2.0) progress notes

*Corben (1997) set a 60% or lower level of achievement as an unsafe result. Criteria were flagged that did not achieve 60% for always present. Note that most criteria did reach 60% or more for present and always present categories.

This criteria has been rewritten to include a statement relating to condition see version 3 of NMCAT (Appendix I). ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

M. Johnson et al.

Table 5

0300 N/R dozing for short periods when awake takes

Criteria relating to legal requirements

off nasal prongs- same continuously reapplied.

Meets criteria

A/Prof XXX requested to put 5 mL betadine around

No

Yes

and into SPC in situ site and then replace SPC to size 18

and keep it clamped with a valve. Procedure completed

without any problems. Patient felt comfortable.

The patientÕs name was recorded

on each page

Educated patient on the reason for keeping IDC-leg

The Health Care Record number

bag which needs replacement weekly.

was recorded on each page The patientÕs date of birth was

recorded on each page

Discussion

There was evidence of the use

of abbreviations from the official list of

A metasynthesis of the literature relating to documen-

approved abbreviations only on each page

tation (Jefferies et al. 2010) highlighted key areas for

There was evidence of the use

improvement in nursing documentation and shaped

of appropriate medical terminology

seven Minimum Standards on Nursing Documentation

on each page Entries on each page were always

and the criteria for a nursing documentation audit

made on behalf of the writer

tool (SSWAHS 2009). The NMCAT is a short, practical

and never on behalf of another person

tool that focuses on the content of nursing documen-

All excessive white space

tation rather than being restricted to only the legal

on each page had lines throughout the space

aspects of nursing documentation.

There was a name, signature and

Several aspects of the design were derived from other

designation on each page

tools or other researcherÕs views. Anderson et al. (2009) proposed that a short tool was needed and the NMCAT requires 6–7 minutes to complete. Time sampling proved to be a useful and practical approach

Text that reflected a collection of abbreviations, that allowed for this shortened time for completing the focusing mostly on nursing tasks with little connection

audit. Although contemporary approaches such as to the patient was common:

using an internet survey tool which allows staff to in- Independent in ADLs. Mobilizing around ward.

put data and receive reports was included, the auditor Regular IVABX given as charted. Obs monitored and

had difficulty getting access to the internet to input stable. v/b husband. No voiced complaints.

data at the ward level. This aspect may be in question Observed to be resting for short periods, easily

at this point, but the authors believe this will be re- rousable. IVF continues via portacath IV A/biotics given

solved with widespread wireless access for nurses at the Afebrile.

ward level. Corben (1997) reviewed the entire record Reporting change in status using objective informa-

of the patient in her work and this approach does have tion and contemporaneous (as events occurred)

merit if not some difficulties with the time required to recording:

complete the audit. Although Muller-Staub et al. 0215 hours obs attended & stable. Nil C/0 chest

(2007) examined diagnoses, interventions and out- pain. 0445 Monitor alarmed HRfl 39 bpm. Pt asleep,

comes using continuous data, the NMCAT has in- snoring loudly. Pt woken up to attend to obs pt denies

cluded essentially categorical data which explores feeling symptoms of same States he was Ôout cold &

nursing interventions and their effectiveness, or patient sound asleepÕ BP now 122/75 HR 66.

outcomes.

The following transcript identifies the patientÕs The problems with retrospective chart audits were response to treatment and prn medication and educa-

outlined by Wong (2009) with the proposal that audits tion is noted:

should be conducted 1 day after the care is given. The 3/07/09 2250 Patient becoming › confused &

NMCAT, in most cases, was completed using the last aggressive contacted RMO stat dose of Haloperidol

24-hours period recorded and would represent a

1.0 mg IMI admin await effect… description of the care delivered within 1 day of the 2400 (patients name) unsettled at handover. At

audit. The ability to question staff about the content is

an advantage in this approach and would be very obs as charted. Note previous dose of Haloperidol given

moment in bed with O 2 prongs reapplied 2L/minutes

effective when audits are conducted by ward nursing await effect.

staff rather than an external auditor. 838

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

10-minute nursing documentation audit tool

The general impression of the text was that nursing objective account of a patientsÕ problem is obtained documentation was a connected series of short state-

using the patientÕs own words to describe the problem: ments often involving abbreviations that may or may

Mr Smith complained of a headache and said that it was not be acceptable across the service. Many local

Ô blurring his visionÕ. Nurses have traditionally used the abbreviations were in use, which in some cases, were

word patient (pt) in nursing notes as the patientÕs name unknown to the auditor and may potentially be mis-

appeared at the top of all pages (addressograph label), understood by casual health staff.

however, this results in a focus often upon the tasks of It was evident that there was little sentence structure

nurses disconnected from any patient problem (Jefferies and the presentation would have been difficult for a

et al. 2010). These authors are trialing a ward-based consumer or the general public to read and understand.

writing coach strategy to explore the possibilities of Health care records are reviewed by legal services and

improving written accounts of patient care through consumers. Consumers often request to read health care

coaching.

records, which is supported, if undertaken in the pres- The nursing documentation audited presented an ence of a medical officer.

objective account of the patientÕs experience of their Karkkainen et al. (2005) suggest that the quality of

condition and the care they received during their nursing documentation reflects the nursesÕ view of their

admission. The legal aspects of nursing documentation documentation. For example, if nurses did not believe

were particularly strong, demonstrating that clinicians that documentation had a useful clinical purpose, nur-

had a good understanding of the importance of ensuring ses did not give a full picture of the care given to

that the patient was identified by their name (label), patients. However, if nurses saw their documentation as

health care record number and date of birth on every an important aid to communication and a guide to care,

page, and that no entry was made on behalf of another their documentation gave a fuller picture of the care

person.

given to the patient (Karkkainen et al. 2005). Another Areas identified for improvement (based on CorbenÕs aspect of nursing documentation that has come to the

60% rule applied to always present category) included: researchersÕ attention anecdotally through discussions

need for a statement in the shift report that identifies the with Directors of Nursing has been the influx of over-

patientÕs status, notation of the patientÕs response to all seas trained nurses who speak English as a second lan-

treatment including medications, using the patientÕs guage. These nurses may be assisted to give fuller

name in the script and documenting the education and descriptions of patient care if they are able to access

psychosocial care provided where appropriate. There descriptions of care through prompts or predictive text.

was limited evidence of nurses recording events when These prompts could potentially be available with the

they happened, with the end of shift reporting tradition introduction of the electronic medical record. The idea

remaining prominent. As Jefferies et al. (2010) notes: of structuring descriptions of care into codes on the

Ô Documenting events as they occur guarantees that electronic medical record, rather than using free text

important information about the patientÕs condition boxes, to ensure the quality of nursing documentation,

and care is not forgotten if subsequent events take placeÕ has been argued by Moss (2007). This author suggests

(p. 120) Ôit can be difficult to reconstruct events at a that these codes would be more easily analysed by all

later timeÕ (p. 122).

health care professionals than any narrative descrip- The inclusion of psychosocial care and education is tions of care given in free text (Moss 2007).

particularly problematic and has been referred to by The content reflected in the text reviewed in this study

other authors (Brooks 1998). Psychosocial care is often often described a series of nursing tasks that were

difficult to put into written language for nurses (Jefferies unrelated to any identified patient problem or sign or

et al. 2010) and therefore often results in a limited symptom. This has been previously reported by other

scope of nursing interventions being reported. Similarly, authors (Brooks 1998, Pearson 2003, Karkkainen et al.

education delivered to the patient or family is often 2005). There was little use of the patientÕs actual name

extensive and details of the education content delivered with the patient being frequently referred to in the

provides evidence of the role of nurse in patient care. abbreviated form of ÔptÕ. The authors believed that not

This may result from the situation where the nurse using a patientÕs name was a mechanism that distanced

delivers education and support while undertaking a the nurse from the patient. Using the patientÕs name

task. This results in only the task of Ôattending the required the nurse to personalize their account of the

woundÕ being reported upon even although much patientÕs care and encourages nurses to involve the

attention was also given to educating the patient about patient in the nursing documentation. For example, an

the care of the wound.

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

M. Johnson et al.

Neither the NMCAT nor the Minimum Standards on Dykes P. (2006) A systematic approach to baseline assessment of Nursing Documentation prescribed the exact words or

nursing documentation and enterprise-wide prioritisation of language or scope of content to be used in nursing electronic conversion. Studies in Health Technology and

Informatics 122, 683–687.

documentation, rather these standards only provide Gebru K., Ahsberg E. & Willman A. (2007) Nursing and medical general direction; defining patient problem, nursing

documentation on patientsÕ cultural background. Journal of interventions and outcomes of care. Various content

Clinical Nursing 16, 2056–2065.

approaches exist throughout the service – systems Gropper E.I. (1988) Does your charting reflect your worth? approach in critical care, activities of daily living in

Geriatric Nursing 9, 99–101.

rehabilitation and aged care and others prefer a prob- Jefferies D., Johnson M. & Griffiths R. (2010) A metastudy of the essentials of quality nursing documentation. International

lem-based or nursing diagnosis approach. The devel- Journal of Nursing Practice 16, 112–124. opment team of the Minimum Standards believed that

Karkkainen O., Bondas T. & Eriksson K. (2005) Documentation only broad guidance should be given to professional

of individual patient care: a qualitative metasynthesis. Nursing nurses rather than a prescriptive text (Jefferies et al.

Ethics 12, 123–132.

2010). Finally, health care documentation is not only Karlsen R. (2007) Improving the nursing documentation: pro- fessional consciousness-raising in a Northern-Norwegian psy-

the responsibility of nurses, but rather an important chiatric hospital. Journal of Psychiatric and Mental Health quality issue for all health care professionals including

Nursing 14, 573–577.

allied health professionals and medical practitioners. von Krogh G. & Naden D. (2008) Implementation of a docu- In conclusion, the NMCAT is a short audit tool that

mentation model comprising nursing terminologies – theoreti- uses time sampling methods to capture 24-hours periods

cal and methodological issues. Journal of Nursing Management of nursing documentation around 1 day after the care is 16, 275–283. Manfredi C. (1986) Reliability and validity of the Phaneuf Nursing

delivered. It has demonstrated face validity and inter- Audit. Western Journal of Nursing Research 8, 168–180. rater reliability (85%) and has been used here prior to

McCormack B. (2003) The meaning of practice development: implementation of Minimum Standards on Nursing

evidence from the field. Collegian 10, 13–16. Documentation. The tool is directly related to the Stan-

Middleton S., Chapman B., Griffiths R. & Chester R. (2005) dards. The structure of the nursing scripts examined Reviewing recommendations of root cause analyses. Australian

Health Review 31, 288–295.

highlights the need for either language support software Moss J. (2007) An analysis of narrative nursing documentation in or additional training in writing prior to undertaking the

an other otherwise structured intensive care clinical informa- transition to electronic format. There is a need for clini-

tion system. AMIA Annual Symposium proceedings 543–547. cians, managers and educators to promote the inclusion

Muller-Staub M., Needham I., Odenbreit M., Lavin M.A. & van of education and psychosocial support, provided to the

Achterberg T. (2007) Improved quality of nursing documen- patient, within nursing documentation. tation: results of a nursing diagnoses, interventions, and out- comes implementation study. International Journal of Nursing

The NMCAT is a useful, reliable and valid tool that Terminologies and Classifications 18, 5–17. clinicians, managers and educators can use to monitor

NSW Health (2008) Principles for Creation, Management Storage aspects of nursing documentation.

and Disposal of Health Care Records, NSW Health, Sydney. Pearson A. (2003) The role of documentation in making nursing work visible. International Journal of Nursing Practice 9, 271–

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ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

10-minute nursing documentation audit tool

Appendix I Nursing and Midwifery Content Audit Tool (NMCAT)

1. Ward / Unit Area: ................................................................................................... 2. Time period covered by this record audit:

Admission to =<24 hours Between >24 hours to <=48 hours after admission Between >48 hours to <=72 hours after admission Between >72 hours to <96 hours after admission Other cases extended periods (describe the situation): ........................................

SECTION B: Nursing Documentation Content Examine the written text, within the time period selected (only 3 shifts are examined am,

pm and night) for this record audit, for any evidence of each of the following criteria and code according to the notes below. Explanatory notes follow.

Absent – Criteria not present in any of the written text Present – Criteria occasionally present (present on notes from one shift, but not notes

from another shift) Always Present – Criteria always present (present in notes from all shifts) Not Rated – Question not applicable to this record

3. The patient’s problem(s) is written in terms ....

of what the patient actually said or what was observed by the nurse

4. There is an entry recording the status of the ...

patient, whether changed or unchanged, on each shift

5. Any change in the patient’s status is supported

by documented objective information 6. Any observation, sign or symptom, is written ..

in terms of what the nurse observed and is not based on the nurse’s assumptions about

the patient

7. The action taken by a nurse when finding a ....

change in the patient’s status is recorded 8. The patient’s response to treatment (other .....

than medication) is stated 9. The patient’s response to medication is ..........

10. The nursing documentation is a chronological .

report of events that describe the patient’s experience from admission to discharge

11. All nursing entries in the patient’s notes are ....

legible ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

M. Johnson et al.

12. There was a recorded and date on every ........

nursing entry in the patient’s note

13. Entries were written as incidents occurred ......

14. Entries were written in a logical and ...............

sequential manner

15. Entries in documentation appear uniquely .......

16. The education and / or psychosocial care .......

provided by nurses is recorded in the notes

17. The patient is referred to by name in the ........

nursing entries of the patient’s notes

Final explanatory notes relating to the criteria and additional information collected within the NMCAT,

Absent Present Always Present

Not Rated

3 Notes are not written Some, but not all, notes

All notes are objectively

No objective

in the patient’s words are objectively written in written in the patient’s

information is

nor what was

the patient’s words or

words or what was

required-(this would

observed by the

what was observed by

observed by the nurse

be a very rare

nurse (e.g.,

the nurse (e.g., patient

(e.g., patient is, patient

occurrence).

comments such as

is, patient states).

states).

appears, seems, etc).Notes that are mostly using subjective language rate as absent.

4 Notes do not include

Some entries within the

Each entry within the

No status would be

a description of the

shift period contains a

shift period contains a

required due to the

patient’s status.

statement regarding the

statement regarding the

context-(this would

patient’s condition. (e.g.

patient’s condition (e.g.

be a rare

the patient’s condition is

the patient’s condition is

occurrence).

deteriorating and he

deteriorating and he

stated that he was

stated that he was

‘having difficulty

‘having difficulty

breathing’).

breathing’). (e.g. Mrs

(e.g. Mrs Smith was

Smith was comfortable

comfortable today and

today and refused all

refused all analgesia).

analgesia). The emphasis is on the status of the patient

5 There is evidence of

Some entries contain

Each entry contains

There is no evidence

a change in the

evidence of a change in

evidence of a change in

of a change in the

patient’s condition,

the patient’s condition,

the patient’s condition

patient’s condition.

but notes do not

and some, but not all,

plus a description of the

That is: existing

include a description

relevant notes include a

observable and recorded

problems continue or

of the patient’s

description of observable signs and symptoms

no problems continue

status, nor any

and recorded signs and

(e.g., coughing up blood,

observable signs or

symptoms (e.g.,

tachycardia of 160bpm)

symptoms.

coughing up blood,

and whether this is an

tachycardia of 160bpm)

improvement or

and whether this is an

deterioration. The

improvement or

emphasis is on objective

deterioration. The

information supporting

emphasis is on objective

change in status.

information.

6 Notes are not written Some, but not all, notes

All notes are objectively

There is no evidence

in terms of

are objectively written in written in terms of

of a change in the

observable

terms of observable

observable behaviour

patient’s condition.

behaviour. Notes

behaviour (e.g., Mr

(e.g., Mr Tablis was

may include

Tablis was found

found clutching at his

assumptions about

clutching at his chest

chest and stated “I can’t

the patient’s

and stated “I can’t

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845

7 There is evidence of deterioration in the patient’s condition, but the notes do not include a description of actions taken by the nurse.

There is evidence of deterioration in the patient’s condition, and some, but not all, relevant notes include a description of actions taken by the nurse (e.g., contacted the medical officer, sat Mrs Faith in the upright position).

There is evidence of deterioration in the patient’s condition, and all relevant notes include

a description of actions taken by the nurse (e.g., contacted the medical officer, sat Mrs Faith in the upright position).

There is no evidence of deterioration in the patient’s condition.

8 There is evidence of the patient receiving treatment, but notes do not include a description of the patient’s response to the treatment. Treatment could include nebulizer, oxygen therapy, TED stockings, repositioning, personal hygiene, changes to the way which the patient ambulates, and counselling

There is evidence of the patient receiving treatment and some, but not all, relevant notes include a description of the patient’s response to the treatment (e.g., TDS dressings applied to Mr Hamilton’s leg wound and wound edges are now raised and pink and the wound surface area is decreasing).Treatment could include nebulizer, oxygen therapy, TED stockings, repositioning, personal hygiene, changes to the way which the patient ambulates, and counselling

There is evidence of the patient receiving treatment and all relevant notes include a description of the patient’s response to the treatment (e.g., TDS dressings applied to Mr Hamilton’s leg wound and wound edges are now raised and pink and the wound surface area is decreasing). Treatment could include nebulizer, oxygen therapy, TED stockings, repositioning, personal hygiene, changes to the way which the patient ambulates, and counselling

There is no evidence of the patient receiving any treatment.

9 There is evidence of the patient receiving

a prn or short-term medication, but notes do not include

a description of the patient’s response to

There is evidence of the patient receiving prn or short- term medication and some, but not all, relevant notes include a description of the patient’s response to the

There is evidence of the patient receiving a prn or short-term medication and all relevant notes include a description of the patient’s response to the medication (e.g., BP

There is no evidence of the patient receiving any prn or short-term medication.

the medication. Note: Short-term medication is a medication commenced to reduce a patient’s blood pressure or a medication that is adjusted according to the patient’s response such as warfarin or insulin.

medication (e.g., BP returned to normal limits 120/80 mmHg following

2 days of XXX) either in the current note or in a separate later note. Note: Short-term medication is

a medication commenced to reduce a patient’s blood pressure or a medication that is adjusted according to the patient’s response such as warfarin or insulin.

returned to normal limits 120/80 mmHg following

2 days of XXX) either in the current note or in a separate later note. Note: Short-term medication is

a medication commenced to reduce a patient’s blood pressure or a medication that is adjusted according to the patient’s response such as warfarin or insulin.

10 Notes do not

describe a progressive series of events in time order.

Some, but not all, notes describe a progressive series of events in time order.

All notes describe a progressive series of events in time order.

There are not enough notes in the time period.

11 All words are

illegible.

Most words are legible.

12 None of the notes include a date or time.

Some, but not all, notes include a date and time.

All notes include a date and time.

13 There is evidence

that unusual events (other than normal activities, e.g. going to the toilet) occurred during the

There is evidence that unusual events (other than normal activities,

e.g. going to the toilet) occurred during the shift and some, but not all,

There is evidence that unusual events (other than normal activities,

e.g. going to the toilet) occurred during the shift and the majority of

There is no evidence that unusual events (other than normal activities, e.g. going to the toilet) occurred during the shift.

shift, but notes are only written at the end of the shift, with no evidence of specific times when events occurred.

relevant notes were written as the incidents occurred, including specific times when incidents occurred.

entries were written as the incidents occurred, including specific times when incidents occurred.

10-minute nursing documentation audit tool

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10-minute nursing documentation audit tool

SECTION D: Record Characteristics and Legal Aspects of Documentation

18. Was the following recorded on each page?

a. Patient’s name b. Health Care Record number c. Patient’s date of birth d. Evidence of the use of abbreviations from the official list of approved abbreviations only e. Name, signature and designation of the nurse writing the report is written legibly at the end of each entry f. Evidence of the use of appropriate medical terminology

g. Entries are made on the behalf of the writer and never on behalf of another person h. All excessive white space has lines throughout the space

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