Abstract
AIMS AND OBJECTIVES: This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed. BACKGROUND: Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation. DESIGN: A qualitative design was used for instrument development. METHODS: Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalized into items and eight experts assessed face and content validity of the Q-DIO. RESULTS: Criteria were developed and operationalized into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88.25% agreement for the scores assigned to the 29 items of the Q-DIO. CONCLUSIONS: The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended. RELEVANCE TO CLINICAL PRACTICE: Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records.
