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.