Quality indicators of the nursing process documentation in clinical practice - Revista Brasileira de Enfermagem

Quality indicators of the nursing process documentation in clinical practice |

ABSTRACT

Objectives:

to propose quality indicators for clinical nursing documentation

Methods:

methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen’s kappa.

Results:

the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services.

Conclusions:

seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.