Development of the Quality of Australian Nursing Documentation in Aged Care ( QANDAC) instrument to assess paper-based and electronic resident records.

Aim To develop an Australian nursing documentation in aged care ( Quality of Australian Nursing Documentation in Aged Care ( QANDAC)) instrument to measure the quality of paper-based and electronic resident records. Methods The instrument was based on the nursing process model and on three attributes of documentation quality identified in a systematic review. The development process involved five phases following approaches to designing criterion-referenced measures. The face and content validities and the inter-rater reliability of the instrument were estimated using a focus group approach and consensus model. Results The instrument contains 34 questions in three sections: completion of nursing history and assessment, description of care process and meeting the requirements of data entry. Estimates of the validity and inter-rater reliability of the instrument gave satisfactory results. Conclusion The QANDAC instrument may be a useful audit tool for quality improvement and research in aged care documentation. [ABSTRACT FROM AUTHOR]