Degree Name

Doctor of Philosophy


School of Information Systems and Technology


Nursing documentation, a major clinical information source in Australian residential aged care, plays a significant role in the management and delivery of care services. In addition to its importance in supporting effective communication between different care team members, high quality nursing documentation is essential to meet accreditation, funding and quality improvement requirements. Electronic nursing documentation systems were implemented in several aged care organisations in an attempt to improve documentation efficiency and utility of data. The effect of the systems on the overall quality of nursing documentation is yet to be validated. In addition, although documentation practice in the aged care sector is generally shaped by legislative requirements, it is unclear how nursing documentation is managed and conducted in reality in different organisations. To our knowledge, limited studies have been conducted in this area internationally and no study has been conducted in Australia. To fill this knowledge gap, this study investigated nursing documentation practices in several Australian residential aged care organisations and compared the quality of nursing documentation between paper-based and electronic documentation systems.

A nursing documentation evaluation framework was established by conducting a systematic literature review of documentation quality and its evaluation approaches and, based on this, developing a nursing documentation audit instrument. Three attributes of nursing documentation quality were identified in the review and addressed by the audit instrument. These are the structure and format, process and content of nursing documentation. The audit instrument addresses different components of nursing documentation in a resident record which follow the five steps of the nursing process model: assessment, problem/diagnosis, goal, intervention and evaluation.

Applying the audit instrument, four nursing documentation audit studies were conducted in nine residential aged care facilities belonging to three aged care organisations. The first study focused on the resident admission forms. The overall completeness and comprehensiveness rates varied significantly among different versions of forms and both rates were higher in the electronic than in the paper-based forms. A comparison was also made for common items, showing higher completeness and comprehensiveness rates in the electronic forms than in their paper-based counterparts. A correlation analysis showed a negative association between the number of items in a form and its completeness rate, but a positive association between the number of items in a form and its comprehensiveness rate.

The second study addressed resident assessment forms. Varying practices of documentation of assessment were found among the three organisations. On average, the quantity of assessment forms was higher in the electronic than in the paper-based records. No improvement was found in the electronic systems in regard to the completeness and timeliness of nursing assessment documentation, but the comprehensiveness of assessment forms was increased in the electronic systems. There was a similar pattern of assessment documentation assigned to various defined assessment categories for both types of systems.

The third study assessed the quality of paper-based and electronic resident nursing care plans (NCPs). Free-text NCPs were found in two organisations and standardized NCPs were found in the other. Various terms were used to label the four sections of the NCPs. The amount of information used to describe a resident problem was higher in the electronic free-text than in the paper-based NCPs. An analysis at the level of each step of the nursing process showed a significant difference between the paperbased and electronic systems in the description of nursing diagnosis/problem in both free-text and standardized NCPs.

The final study compared the quality of documentation structure, format and process between the paper-based and electronic resident records. The results of assessment by 10 relevant questions in the instrument suggested a higher mean total score for each electronic than for each paper-based record.

This research revealed that the electronic documentation systems appear to generate better data than the paper-based systems in terms of documentation structure, format and process. The content of nursing documentation could be determined by complex underlying factors. To meet care, management and nursing development needs, electronic documentation systems need to be integrated seamlessly with other relevant factors to improve documentation practice and quality in residential aged care.