title: Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO.
abstract: OBJECTIVE
  This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed.
  
  
  BACKGROUND
  Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation.
  
  
  METHODS
  A qualitative design was used for instrument development.
  
  
  METHODS
  Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalized into items and eight experts assessed face and content validity of the Q-DIO.
  
  
  RESULTS
  Criteria were developed and operationalized into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88.25% agreement for the scores assigned to the 29 items of the Q-DIO.
  
  
  CONCLUSIONS
  The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended.
  
  
  CONCLUSIONS
  Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records.
authors.affiliation: Pflege PBS, Bern, Switzerland. muellerstaub@bluewin.ch
authors.forename: Maria
authors.initials: M
authors.lastname: Müller-Staub
authors.forename: Margaret
authors.initials: M
authors.lastname: Lunney
authors.forename: Matthias
authors.initials: M
authors.lastname: Odenbreit
authors.forename: Ian
authors.initials: I
authors.lastname: Needham
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: Lavin
authors.forename: Theo
authors.initials: T
authors.lastname: van Achterberg
mesh_terms: D001291:Attitude of Health Personnel; D004282:Documentation / Q000592:standards; D017144:Focus Groups; D006801:Humans; D009726:Nurses / Q000523:psychology; D009731:Nursing Audit / Q000379:methods* / Q000592:standards; D009733:Nursing Diagnosis / Q000592:standards; D015403:Nursing Evaluation Research; D015404:Nursing Methodology Research; D009737:Nursing Records / Q000592:standards; D015588:Observer Variation; D010043:Outcome and Process Assessment, Health Care / Q000379:methods* / Q000592:standards; D010347:Patient Care Planning / Q000592:standards; D010865:Pilot Projects; D011594:Psychometrics; D036301:Qualitative Research; D011787:Quality of Health Care / Q000592:standards; D012680:Sensitivity and Specificity; D018875:Vocabulary, Controlled