Article

Development of an audit instrument for nursing care plans in the patient record.

Karolinska Hospital, Department of Nursing, Karolinska Institutet, Stockholm, Sweden.
Quality in Health Care 03/2000; 9(1):6-13. DOI: 10.1136/qhc.9.1.6
Source: PubMed

ABSTRACT To develop, validate, and test the reliability of an audit instrument that measures the extent to which patient records describe important aspects of nursing care.
Twenty records from each of three hospital wards were collected and audited. The auditors were registered nurses with a knowledge of nursing documentation in accordance with the VIPS model--a model designed to structure nursing documentation. (VIPS is an acronym formed from the Swedish words for wellbeing, integrity, prevention, and security.)
An audit instrument was developed by determining specific criteria to be met. The audit questions were aimed at revealing the content of the patient for nursing assessment, nursing diagnosis, planned interventions, and outcome. Each of the 60 records was reviewed by the three auditors independently and the reliability of the instrument was tested by calculating the inter-rater reliability coefficient. Content validity was tested by using an expert panel and calculating the content validity ratio. The criterion related validity was estimated by the correlation between the score of the Cat-ch-Ing instrument and the score of an earlier developed and used audit instrument. The results were then tested by using Pearson's correlation coefficient.
The new audit instrument, named Cat-ch-Ing, consists of 17 questions designed to judge the nursing documentation. Both quantity and quality variables are judged on a rating scale from zero to three, with a maximum score of 80. The inter-rater reliability coefficients were 0.98, 0.98, and 0.92, respectively for each group of 20 records, the content validity ratio ranged between 0.20 and 1.0 and the criterion related validity showed a significant correlation of r = 0.68 (p < 0.0001, 95% CI 0.57 to 0.76) between the two audit instruments.
The Cat-ch-Ing instrument has proved to be a valid and reliable audit instrument for nursing records when the VIPS model is used as the basis of the documentation.

2 Bookmarks
 · 
531 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation. A quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist. There were no differences between a nurse's demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program. Although some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.
    Journal of Multidisciplinary Healthcare 01/2013; 6:441-450.
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To develop, validate and test the reliability of a measurement instrument that measures the extent to which records describe essential aspects of nursing care such as the admission report, nursing diagnoses, interventions, and progress and outcome evaluations. A measurement instrument was developed based on the Cat-ch-Ing instrument and the Scale for Degrees of Accuracy in Nursing Diagnoses. A record screening was conducted in 7 hospitals in the Netherlands. Content validity was tested by using two Delphi panels. Each of the 250 records was assessed by two reviewers independently. The reliability of the instrument was tested by calculating Cohen's weighted Kappa inter-rater reliability coefficient of 250 records and 12 reviewers. Internal consistency was calculated by using Cronbach's alpha. The new measurement instrument, named D-Catch, consists of six items. Quantity and quality variables were used to judge the accuracy of the nursing documentation. Internal consistency: Cronbach's Alpha 0.722. The inter-rater reliability coefficients were between 0.397-1.000. The D-Catch instrument was estimated to be a valid and reliable measurement instrument for nursing records in hospitals in the Netherlands. An adverse effect on the inter-rater reliability may have been that, specifically in long stay situations, documentation forms with diagnoses, interventions and outcomes were often unstructured and found to be repetitious.
    Studies in health technology and informatics 02/2009; 146:297-300.
  • [Show abstract] [Hide abstract]
    ABSTRACT: This study was designed to gain information on the quality of nursing care based on the comments in nursing records. The specific aims of the study were to find out if the patients‘ (i) individual needs are assessed, the goals for nursing care are set, and the nursing interventions are determined; (ii) if the patients’ needs are met and (iii) if goal achievement is regularly evaluated by including comments in nursing documents. In addition, the study aimed to describe the up-to-dateness of nursing care plans as well as the frequency of making daily notes. The data were collected on 36 wards of four residential homes. A 30% sample of the nursing documents on each ward was collected (n = 332) using the Senior Monitor instrument. The documents studied were mainly nursing care plans and daily note sheets. Seventy-three per cent of the nursing home residents had an up-to-date nursing care plan at the time of data collection. The main results demonstrated that a written statement on the patient's mental ability was lacking in every fourth document although 75% of the patients suffer from at least moderate dementia in Finnish long-term care institutions. Development activities should also be targeted to the documentation of clear and concrete means by which patients’ independent functioning is supported. In addition, evaluation was the area that warranted attention and development activities since only every fourth record included information on changes in the patients’ functional capability. Although a lot of in-service training has been focused on improving the documentation practices, there is still a need for development. The means by which knowledge is transferred to guide the practice should be carefully considered. Also forms should be developed to meet the special requirements for recording nursing care in long-term care settings.
    Scandinavian Journal of Caring Sciences 02/2004; 18(1):72 - 81. · 0.89 Impact Factor

Full-text

View
24 Downloads
Available from