Development of the quality of Australian nursing documentation in aged care (QANDAC) instrument to measure 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 has a potential as a useful audit tool for the purposes of quality improvement and research in aged care documentation.