Assessment of Nursing Documentation Quality

The high quality of nursing documentation is a prerequisite for the secondary use of data. Poor-quality data can lead to incorrect decision-making. This study aimed to describe the assessment of nursing documentation quality and the utilization of this assessment data in the knowledge-based management and development of daily nursing practices. Using a cross-sectional study design, an online survey of information systems for registered nurses in Finland was conducted in spring 2023. A total of 2970 nurses responded. Descriptive methods were used to characterize the frequency of the secondary use of nursing data. Across units, nursing documentation quality was not assessed in 51% of cases, results were not reviewed in 66% of units, and nursing data were not used for knowledge-based management in 58% of units. In private health care and social services, nursing documentation reviews occurred in 21% of units, and 24% reported using nursing data for knowledge-based management. In contrast, public hospitals demonstrated lower engagement, with only 17% of units reviewing nursing documentation and 13% utilizing nursing data for management purposes. The private sector led in the secondary use of nursing data compared with other sectors. Nursing managers consistently provided more positive responses than nurses across all aspects of secondary use of data. This difference may stem from the fact that nursing managers use secondary data for daily management.