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The Nursing and Midwifery Content Audit Tool (NMCAT): A short nursing
documentation audit tool

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DOI: 10.1111/j.1365-2834.2010.01156.x · Source: PubMed

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Journal of Nursing Management, 2010, 18, 832–845

The Nursing and Midwifery Content Audit Tool (NMCAT): a short

nursing documentation audit tool

1,2 3
MAREE JOHNSON R N , B A p p S c i , M A p p S c i , PhD , DIANA JEFFERIES RN, BA (Hons), PhD (USyD) and
RACHEL LANGDON B A p p S c i , B A ( H o n s ) 4
1
Director, Centre for Applied Nursing Research, (a joint venture of the SSWAHS and UWS), 2Professor of Nursing,
School of Nursing & Midwifery, University of Western Sydney, Sydney, 3Nurse Educator-Clinical Research, Centre
for Applied Nursing Research, Liverpool and 4Research Assistant, Centre for Applied Nursing Research, Liverpool,
NSW, Australia

Correspondence J O H N S O N M . , J E F F E R I E S D . & L A N G D O N R . (2010) Journal of Nursing Management 18, 832–

Diana Jefferies 845
Centre for Applied Nursing The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing
Research documentation audit tool
Locked Bag 7103
Liverpool, 1871 NSW Background The Nursing and Midwifery Content Audit Tool (NMCAT) was
Australia developed to monitor the quality of nursing documentation.
E-mail: Methods A health care record audit was conducted on 200 records. Using a time-
Diana.jefferies@sswahs.nsw.gov.au sampling approach, recent nursing documentation was examined. Inter-rater
reliability was determined at 85% agreement between two raters.
Results The NMCAT criteria relating to the recording of the patientsÕ health status,
use of objective information and logical presentation were met to a high level. The
patientsÕ response to treatment or nursing interventions including medications
requires attention. The recording of events immediately after they have occurred
was limited. The structure of the sentences and language used, restricted the read-
ability of the documentation. The widespread use of local abbreviations, often
connected together to form the text, was problematic.
Conclusions The present study provides new audit solutions based on time-
sampling approaches and focused evidence-based criteria. The use of language
support software and writing coaches to improve the presentation of nursing doc-
umentation is recommended.
Implications for Nursing Management The NMCAT is a time-efficient tool avail-
able to managers for monitoring the quality of nursing documentation, either at a
unit level or across health facilities to demonstrate compliance with quality
standards.
Keywords: audit, communication, documentation, evidenced-based policy, innovation

Accepted for publication: 26 June 2010

cians to see the benefits (Gropper 1988). Quality doc-

Introduction
umentation details patientsÕ problems, nursesÕ actions or
Although nursing documentation is a valuable tool for interventions and patient outcomes and is Ôan essential
communicating patient information to nurses and other component of professional practiceÕ (Wong 2009,
health professionals, it is often difficult for busy clini- p. E1). The role of the nurse in assisting the recovery of
DOI: 10.1111/j.1365-2834.2010.01156.x
832 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd
 10-minute nursing documentation audit tool

the patient can be made explicit through nursing notes team informed of the patientÕs condition, their care and
(Karlsen 2007) and can be examined through research their response to that care (Gebru et al. 2007) and was
(McCormack 2003). From the perspective of other the basis of the Minimum Standards on Nursing Doc-
health professionals, the utility of nursing documenta- umentation.
tion is often diminished by the over abundance of Two of the authors initially undertook a systematic
Ôroutine notesÕ as noted by general practitioners review of existing literature to design the seven stan-
(Tornvall & Wilhelmsson 2008). Communication, dards of quality nursing documentation. This entailed a
whether written or oral, has been identified as con- search of published papers on CINAHL 1982 to April
tributing to approximately 50% of all adverse events Week 3 2008, and MEDLINE 1996 to April 2008 and
for patients (Middleton et al. 2005). With the looming limited to the English language, using the following
introduction of electronic health care records, nurses are terms: attitude, audit, care, culture, documentation,
well aware of the need to improve their written com- guideline, health, in service, legal, liability, medical,
munication of the care they deliver. Indeed, one author nurses, nursing, organizational, patient, personnel,
suggests that the assessment of the current state of planning, practice, quality, records, research and
nursing documentation is an important initial step in the training (Jefferies et al. 2010). Some 71 articles were
conversion to electronic documentation (Dykes 2006). identified and quality scoring and thematic analysis was
In addition, one Australian study (Considine et al. undertaken. Using a meta-synthesis approach, seven key
2006) demonstrated that the introduction of standards themes emerged from the process and formed the
has successfully led to an improvement in nursing doc- standards. The seven minimum standards were that
umentation. This present study aims to develop and test nursing documentation should: be patient centred, must
a short audit tool to evaluate the implementation of contain the actual work of nurses including education
documentation standards and for continuous monitor- and psychosocial support, be written to reflect the
ing of nursesÕ written documentation of their care. objective clinical judgement of the nurse, be presented
This study examined the development and testing of in a logical and sequential manner, be written contem-
the Nursing and Midwifery Content Audit Tool poraneously (or immediately after events occur), record
(NMCAT) specifically designed to reflect the standards variances in care within and beyond the health care
of quality documentation derived from a systematic record and fulfill legal requirements (see Table 1).
review of the literature undertaken by the authors The standards were broad in nature, and no attempt
(Jefferies et al. 2010). In addition, initial pre-imple- was made to define the content of nursing notes. Many
mentation data on nursing documentation, using the diverse formats exist such as nursing diagnoses, nursing
NMCAT tool, are presented. intervention classification and nursing outcome classi-
fication systems (von Krogh & Naden 2008), a systems
approach (Anderson et al. 2009), and activities of daily
living (Rajkovic et al. 2009), and this issue of format
Developing the standards for quality nursing has been addressed within the varying clinical units and
documentation was not considered within these standards. Engagement
A Health Care Record has been defined as Ôa documented of clinicians and consumers was a critical part of the
account of a personÕs health, illness or treatment in a process of standard development.
hard copy or electronic formÕ (NSW Health 2008, p. 3). An essential part of the implementation plan, beyond
A definition for nursing and midwifery documenta- an on-line education programme, was the initial audit
tion was developed as part of the process of standard of a sample of health care records across the service. A
development and is used in this study: tool was required that captured aspects of the seven
standards. It should be noted that regular checks of
ÔNursing and midwifery documentation is a pro-
nursing and other health professional documentation
cess in which the patientÕs experience from
are undertaken as part of an accreditation process and
admission to discharge is recorded in a manner
these audits focus on legal requirements only and not
which enables all clinical staff involved in the
the content of the nursing notes. In Australia, an inde-
patientÕs care to detect changes in the patientÕs
pendent body, the Australian Council on Healthcare
condition and the patientÕs response to treatment
Standards (ACHS), reviews hospitals at annual or tri-
and care deliveryÕ.
ennial periods to determine whether a hospital has met
This definition emphasized the role of nursing docu- the required standards for acute hospitals. Hospitals
mentation in keeping all members of the health care voluntarily participate in the ACHS Evaluation and

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845 833
M. Johnson et al.

Table 1
Relationship between standards and criteria used in the Nursing and Midwifery Content Audit Tool (NMCAT)

Minimum standards of nursing documentation Criteria within NMCAT audit tool

1. Should be patient centred The patient was referred to by name in the nursing progress notes.
There was an entry recording the status of the patient, whether changed or
unchanged, on each shift.
Any change in the patientÕs status was indicated and objective information documented.
The action taken by a nurse when finding a change in the patientÕs status was recorded.
The patientÕs response to medication was stated.
The patientÕs response to treatment (other than medication) was stated.
2. Must contain the actual work of nurses The action taken by a nurse when finding a change in the patientÕs status was recorded.
including education and psychosocial support The education and/or psychosocial care provided by nurses was recorded in the notes.
3. Is written to reflect the objective clinical The patientÕs problem(s) was written in terms of what the patient actually said or what
judgment of the nurse was observed by the nurse.
Any change in the patientÕs status was indicated and objective information documented.
The observation, sign or symptom, was written in terms of what the nurse observed and
was not based on the nurseÕs assumptions about the patient.
4. Presented in a logical and sequential manner The nursing documentation was a chronological report of events that describe the
patientÕs experience from admission to discharge.
Entries were written in a logical and sequential manner.
The action taken by a nurse when finding a change in the patientÕs status was recorded.
The patientÕs response to medication was stated.
The patientÕs response to treatment (other than medication) was stated.
5. Written contemporaneously, or as events occur Entries were written as incidents (unusual events) occurred.
6. Should record variances in care within and Entries in documentation appeared uniquely.
beyond the health care record
7. Should fulfill legal requirements All entries in the nursing documentation were legible.
There was a recorded date and time on every entry in the nursing documentation.

Criteria could relate to more than one standard.

Quality Improvement Program (EQuIP) (ACHS 2009) reliable tool with some limitations. In 1997, Corben
which is conducted by independent assessors. 1997, critiqued ManfrediÕs work and concluded that
This approach is consistent with the process defined Phaneuf was the only existing tool, but was unsuitable for
by Anderson et al. (2009) where a Best Practice Council the British health system and had varying levels of validity
was formed and followed the ÔSt. LukeÕs Evidence Based and reliability in the subscales. Corben developed an-
Practice ModelÕ to collect and appraise the evidence, other audit tool known as the Buckinghamshire nursing
integrate the evidence with clinical expertise, patient record audit tool. This tool was derived from the criteria
preferences and values and evaluate the practice change within the UKCC Standards on Records and Record
(Anderson et al. 2009, p. 85). However, Anderson et al. Keeping (1992) and included sections on the utilization of
(2009) raised concerns about nurses conducting regular the nursing process, questions on individualized care and
audits which were so time consuming that there was patient involvement, teaching and health promotion and
little time left for implementing strategies to address communication with other disciplines. This audit
deficiencies. required examination of a complete set of documen-
tation from admission to discharge and relevant charts.
A practitioner and facilitator are recommended to
Tools to measure the quality of nursing notes
undertake the audit thus supporting an educational
Audit tools have often been used as part of the general experience. Corben set a 60% or lower level of achieve-
health service accreditation process. However, a review ment as an unsafe result. In conclusion, Corben (1997)
of the literature did highlight that several tools had been noted that this audit tool was the only one available for
developed by nurses for this purpose. The Phaneuf British documentation.
Nursing Audit is one of the earliest tools to focus on Another aspect of chart auditing raised by Wong is
reporting and recording (Phaneuf 1976, Manfredi 1986). timing of the audit. Wong (2009) noted that most chart
The Phaeuf is a 50-item instrument that measures pro- audits are done retrospectively which does not allow the
fessional nursing. Documentation has five items within auditors to check on the care that is given and Wong
the tool and is rated as yes, no, uncertain or does not recommends that the chart audit be done 1 day after the
apply (Manfredi 1986). Manfredi (1986) demonstrated care is given. WongÕs (2009) audit tool covered vital
that the Phaneuf tool was a comprehensive, valid and signs, admission forms, discharge planning, system

834 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845
 10-minute nursing documentation audit tool

assess charting, progress charting, intravenous fluids areas of concern and then reaudit at a later time. Tools
and labelling, fluid balance and other risk management to measure nursing documentation often focus on legal
charts such as fall prevention, deep venous thrombosis aspects and not much more, while this audit tool also
prophylaxis and skin assessment. The audit was con- focuses on content.
ducted by a nurse educator. The NMCAT is a concur- Several key aspects included in the NMCAT were: a
rent audit, and records are accessed on the ward unit time sampling approach, examination of the content as
while actively in use. well as the legal requirements of documentation and
Another aspect is the use of technology to conduct the capture of the text or actual language used by nurses to
audit. In one study in the emergency department, an demonstrate the areas of strength and weakness. The
automated audit system was introduced to scan through NMCAT criteria were designed to relate to the standards
documentation and notify nurses of areas omitted for quality nursing documentation (Jefferies et al. 2010).
(Wainwright et al. 2008). The Nurse Documentation The final criteria included in the NMCAT tool are
Improvement Tool (END-IT) used peer mentoring to presented in Table 1 and in Appendix I. As can be seen
enhance the Ôaccountability in documentationÕ (Wain- from Table 1, the NMCAT criteria could have been re-
wright et al. 2008, p. 16). lated to more than one standard. Therefore, the aim of the
Another approach has been to review the text of present study was to develop and test the NMCAT in a
many records and glean the essence of the process of large metropolitan health service. To pilot test the utility
nursing notes as undertaken by Karlsen (2007) within a of the tool and reporting mechanism to Directors of
Norwegian psychiatric hospital. Karlsen found evidence Nursing & Midwifery was the focus, although details of
of private nursing plans (written in a way that has the inter-rater reliability were also examined. This study
limited transference of information), hidden nursing also provided initial pre-implementation data for the
plans (recordings of where the patient is and what he/ introduction of the Minimum Standards on Nursing
she is doing) and local diagnostic systems using local Documentation project implementation.
language. This process of reading and understanding
the text is valuable. The authors have included an
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, 832–845 835
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
Monkey, an internet-based data entry and reporting 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
Table 2
discharge and other cases of extended periods. The Inter-rater reliability
auditor was required to locate three nursing entries (or a
Per cent agreement
24-hours time period). The large sample size ensured a
distribution across the usual time periods for inpatients. Time 1 Time 2
Criteria n = 10 (%) n = 10 (%)

The patientÕs problem was written 60 70

Procedure in terms of what the patient
actually said or what was
The Director of Nursing and Midwifery Services
observed by the nurse
(DON&MS) from each hospital participating in the There was an entry recording 40 100
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 80
and was generally well supported by staff within the unit. 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 80 70
symptom, was written in terms of
In most cases, these data were placed on a hard copy form 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 80
lector, inter-rater reliability testing was also undertaken.
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 70 70
ward areas and the DON&MS. Aggregated data from treatment was stated
The patientÕs response to 60 80
all services were presented in a summary report with medication was stated
recommendations to the Area DON&MS and all The nursing documentation was 80 90
DON&MS and this provided the benchmarks for pre- a chronological report of events
that described the patientÕs experience
implementation of the standards. from admission to discharge
Ethical approval was sought and obtained from two All entries in the nursing 80 100
Health and Research Ethics Committees covering all the documentation were legible
There was a recorded time and 90 80
hospitals participating in the study.
date on every entry in the nursing
documentation
Entries were written as incidents occurred 30 100
Results Entries were written in a logical 90 100
and sequential manner
Inter-rater reliability was confirmed on Time 2 with Entries in documentation appear uniquely 40 90
most criteria achieving at least 70% agreement between The education and/or psychosocial 70 20
the raters (see Table 2). The last criterion relating to care provided by nurses is
recorded in the notes
psychosocial care and education was further defined to
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
cases included medical-surgical patient scenarios, mental health
agreement was 81% or 85% excluding the education
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.

836 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 56 (28.0)
Between 25 and 48 hours of admission 43 (21.5) terion for staff in hospitals participating in the present
Between 49 and 72 hours of admission 44 (22.0) study and was accordingly infrequently recorded
Between 73 and 96 hours of admission 40 (20.0) (11%). The purpose of this criterion is to personalize
Prior to discharge 4 (2.0)
Other 13 (6.5) the records for the patient and nurse and allow the
Total 200 (100) 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)

Absent no. Sometimes Always present Not rated

Criterion relating to content of nursing documentation No. (%) present no. (%) no. (%) no. (%)

The patientÕs problem was written in terms of what the patient 200 4 (2.0) 28 (14.0) 168 (84.0) 0
actually said or what was observed by the nurse
There was an entry recording the status of the patient, whether 194 15 (7.73) 46 (23.71) 133 (68.55) 6
changed or unchanged, on each shift
Any change in the patientÕs status was indicated and objective 159 4 (2.51) 35 (22.01) 120 (75.47) 49
information documented
The observation, a sign or a symptom, was written in terms of what 193 1 (0.51) 38 (19.68) 154 (79.79) 7
the nurse observed and was not based on the nurseÕs
assumptions about the patient
The patientÕs response to treatment was stated 132 15 (11.36) 42 (31.81) 75* (56.81) 68
The patientÕs response to medication was stated 85 31 (36.47) 25 (29.41) 29* (34.11) 115
The nursing documentation was a chronological report of events 186 10 (5.37) 5 (2.68) 171 (91.93) 14
that described the patientÕs experience from admission to discharge
All entries in the nursing documentation were legible 200 1 (0.5) 67 (33.5) 132 (66.0) 0
There was a recorded time and date on every entry in the 200 2 (1.0) 76 (38.0) 122 (61.0) 0
nursing documentation
Entries were written as incidents occurred 192 112 (58.33) 53 (27.60) 27* (14.06) 8
Entries were written in a logical and sequential manner 187 6 (3.20) 7 (3.74) 173 (92.51) 13
Entries in documentation appear uniquely 198 5 (2.52) 41 (20.70) 152 (76.76) 2
The education and/or psychosocial care provided by nurses is 23 2 (8.69) 21 (91.30) 0* (0.0) 177
recorded in the notes 
The nurse refers to the patient by name in the nursing 200 178 (89) 18 (9.0) 4* (2.0) 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, 832–845 837
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
Criterion No. (%) No. (%) and keep it clamped with a valve. Procedure completed
without any problems. Patient felt comfortable.
The patientÕs name was recorded 31 (15.5) 169 (84.5)
on each page Educated patient on the reason for keeping IDC-leg
The Health Care Record number 31 (15.5) 169 (84.5) bag which needs replacement weekly.
was recorded on each page
The patientÕs date of birth was 31 (15.5) 169 (84.5)
recorded on each page Discussion
There was evidence of the use 160 (80.5) 39 (19.5)
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 4 (2.0) 195 (97.5) improvement in nursing documentation and shaped
of appropriate medical terminology seven Minimum Standards on Nursing Documentation
on each page
and the criteria for a nursing documentation audit
Entries on each page were always 10 (5.0) 190 (95.0)
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 2 (1.0) 198 (99.0) 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 118 (65.6) 62 (34.4) 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
moment in bed with O2 prongs reapplied 2L/minutes an advantage in this approach and would be very
obs as charted. Note previous dose of Haloperidol given 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 Ôblurring 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 ÔDocumenting 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, 832–845 839
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
electronic conversion. Studies in Health Technology and
language or scope of content to be used in nursing
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.
Jefferies D., Johnson M. & Griffiths R. (2010) A metastudy of the
rehabilitation and aged care and others prefer a prob-
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.
Karlsen R. (2007) Improving the nursing documentation: pro-
2010). Finally, health care documentation is not only
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
16, 275–283.
of nursing documentation around 1 day after the care is
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)
Reviewing recommendations of root cause analyses. Australian
dards. The structure of the nursing scripts examined
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-
tation: results of a nursing diagnoses, interventions, and out-
patient, within nursing documentation. 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–
References 271.
Phaneuf M. (1976) The Nursing Audit: Self-regulation in Nursing
Anderson J.J., Mokracek M. & Lindy C.N. (2009) A nursing Practice, 2nd edn. Appleton-Century-Crofts, New York.
quality program driven by evidence-based practice. Nursing Rajkovic U., Sustersic O. & Rajkovic V. (2009) E-documentation
Clinics of North America 44, 83–91. as a process management tool for nursing care in hospitals.
Australian Council on Healthcare Standards (ACHS) (2009) The Studies in Health Technology and Informatics 146, 291–296.
Australian Council on Healthcare Standards National Report Sydney South West Area Health Service (2009) Minimum Stan-
on Health Services Accreditation Performance 2007–2008. dards on Nursing Documentation. SSWAHS, Sydney.
ACHS, Ultimo. Tornvall E. & Wilhelmsson S. (2008) Nursing documentation for
Brooks J.T. (1998) An analysis of nursing documentation as a communicating and evaluating care. Journal of Clinical Nurs-
reflection of actual nurse work. Medsurg Nursing 7, 189–198. ing 17, 2116–2124.
Considine J., Potter R. & Jenkins J. (2006) Can written nursing Wainwright G.A., Stehly C.D. & Wittman-Price R.A. (2008)
practice standards improve documentation of initial assessment of Emergency nurse documentation improvement tool. Journal of
ED patients? Australasian Emergency Nursing Journal 9, 11–18. Trauma Nursing 15, 16–18.
Corben V. (1997) The Buckinghamshire nursing record tool: a Wong F.W. (2009) Chart audit: strategies to improve quality of
unique approach to documentation. Journal of Nursing Man- nursing documentation. Journal for Nurses in Staff Develop-
agement 5, 289–293. ment 25, E1–E6.

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 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

Absent Present Always Not

Present Rated

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 .......... ........... ........... ..........

stated

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, 832–845 841
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 breathe”).
condition. breathe”).

842 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845
 10-minute nursing documentation audit tool

7 There is evidence of There is evidence of There is evidence of There is no evidence

deterioration in the deterioration in the deterioration in the of deterioration in the
patient’s condition, patient’s condition, and patient’s condition, and patient’s condition.
but the notes do not some, but not all, all relevant notes include
include a description relevant notes include a a description of actions
of actions taken by description of actions taken by the nurse (e.g.,
the nurse. taken by the nurse (e.g., contacted the medical
contacted the medical officer, sat Mrs Faith in
officer, sat Mrs Faith in the upright position).
the upright position).
8 There is evidence of There is evidence of the There is evidence of the There is no evidence
the patient receiving patient receiving patient receiving of the patient
treatment, but notes treatment and some, but treatment and all receiving any
do not include a not all, relevant notes relevant notes include a treatment.
description of the include a description of description of the
patient’s response to the patient’s response to patient’s response to the
the treatment. the treatment (e.g., TDS treatment (e.g., TDS
Treatment could dressings applied to Mr dressings applied to Mr
include nebulizer, Hamilton’s leg wound Hamilton’s leg wound
oxygen therapy, TED and wound edges are and wound edges are
stockings, now raised and pink and now raised and pink and
repositioning, the wound surface area the wound surface area
personal hygiene, is decreasing).Treatment is decreasing). Treatment
changes to the way could include nebulizer, could include nebulizer,
which the patient oxygen therapy, TED oxygen therapy, TED
ambulates, and stockings, repositioning, stockings, repositioning,
counselling personal hygiene, personal hygiene,
changes to the way changes to the way
which the patient which the patient
ambulates, and ambulates, and
counselling counselling
9 There is evidence of There is evidence of the There is evidence of the There is no evidence
the patient receiving patient receiving prn or patient receiving a prn or of the patient
a prn or short-term short- term medication short-term medication receiving any prn or
medication, but and some, but not all, and all relevant notes short-term
notes do not include relevant notes include a include a description of medication.
a description of the description of the the patient’s response to
patient’s response to patient’s response to the the medication (e.g., BP
the medication. medication (e.g., BP returned to normal limits
Note: returned to normal limits 120/80 mmHg following
Short-term 120/80 mmHg following 2 days of XXX) either in
medication is a 2 days of XXX) either in the current note or in a
medication the current note or in a separate later note.
commenced to separate later note. Note:
reduce a patient’s Note: Short-term medication is
blood pressure or a Short-term medication is a medication commenced
medication that is a medication to reduce a patient’s
adjusted according to commenced to reduce a blood pressure or a
the patient’s patient’s blood pressure medication that is
response such as or a medication that is adjusted according to the
warfarin or insulin. adjusted according to patient’s response such
the patient’s response as warfarin or insulin.
such as warfarin or
insulin.
10 Notes do not Some, but not all, notes All notes describe a There are not enough
describe a describe a progressive progressive series of notes in the time
progressive series of series of events in time events in time order. period.
events in time order. order.
11 All words are Most words are legible.
illegible.
12 None of the notes Some, but not all, notes All notes include a date
include a date or include a date and time. and time.
time.
13 There is evidence There is evidence that There is evidence that There is no evidence
that unusual events unusual events (other unusual events (other that unusual events
(other than normal than normal activities, than normal activities, (other than normal
activities, e.g. going e.g. going to the toilet) e.g. going to the toilet) activities, e.g. going
to the toilet) occurred during the shift occurred during the shift to the toilet) occurred
occurred during the and some, but not all, and the majority of during the shift.
shift, but notes are relevant notes were entries were written as
only written at the written as the incidents the incidents occurred,
end of the shift, with occurred, including including specific times
no evidence of specific times when when incidents occurred.
specific times when incidents occurred.
events occurred.

ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845 843
M. Johnson et al.

14 There is evidence of There is evidence of There is evidence of There is no evidence

events occurring events occurring during events occurring during that events occurred
during the shift, but the shift, and some, but the shift, and all notes during the shift.
notations are made not all, notes describe describe the pattern of
out of sequence the pattern of events events appropriately and
(e.g., referring to a appropriately and in a in a logical and
resolved problem in logical and sequential sequential order (e.g.,
an unusual order (e.g., procedure, procedure, observations
sequence, recording observations for for complications,
of events on dates or complications, preparation for
at times that have preparation for discharge).
not followed the discharge).
event appropriately).
15 Notes include normal Some, but not all notes, There is no evidence of Long term patients
data values (BP, include normal data duplication or normal with no routine daily
temperature, etc) values (BP, temperature, data values (BP, observations.
that is also recorded, etc) that is also temperature, etc), with
signed and dated on recorded, signed and this data being recorded
other nursing charts dated on other nursing only on other nursing
(i.e., duplication). charts (i.e., some charts (i.e., no
duplication). duplication).
16 There is no evidence There is evidence that There is no evidence
of written education and / or that education or
documentation of psychosocial support is psychosocial support
any education or being received by the is required.
psychosocial support patient, and relevant
being delivered, notes document the
although the provision by nurses.
patient’s clinical
condition would
require such care.

17 The patient is never The patient is The patient is always

referred to by name sometimes, but not referred to by name
(e.g., patient rather always, referred to by (e.g., Mrs Nguyen rather
than Mrs Nguyen). name (e.g., Mrs Nguyen than the patient).
rather than the patient).

SECTION C: Transcription of documentation

For every 10th record, please transcribe verbatim the text for the 24 hour period
selected for this record audit. Do not record the patient’s name or MRN, using a code
number or pseudonym of necessary. Please use the back of this page and additional pages
if necessary.

Record No.: ...................................................................................................................

Audit Reviewer’s Name: ..................................................................................................

Shift 1: ..........................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

Shift 2: ..........................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

Shift 3: ..........................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

.....................................................................................................................................

844 ª 2010 The Authors. Journal compilation ª 2010 Blackwell Publishing Ltd, Journal of Nursing Management, 18, 832–845
 10-minute nursing documentation audit tool

SECTION D: Record Characteristics and Legal Aspects of Documentation

18. Was the following recorded on each page?

Criteria Yes No N/A

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

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

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