Article

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

Full-text

Available from: Catrin Björvell, Sep 02, 2015
Papers
Development of an audit instrument for nursing
care plans in the patient record
C Björvell, I Thorell-Ekstrand, R Wredling
Abstract
Objectives—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.
Material—Twenty records from each of
three hospital wards were collected and
audited. The auditors were registered
nurses with a knowledge of nursing docu-
mentation in accordance with the VIPS
model—a model designed to structure
nursing documentation. (VIPS is an acro-
nym formed from the Swedish words for
wellbeing, integrity, prevention, and secu-
rity.)
Methods—An audit instrument was devel-
oped 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 calculat-
ing the inter-rater reliability coeYcient.
Content validity was tested by using an
expert panel and calculating the content
validity ratio. The criterion related valid-
ity 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 coeYcient.
Results—The new audit instrument,
named Cat-ch-Ing, consists of 17 ques-
tions designed to judge the nursing docu-
mentation. 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 coeYcients
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.
Conclusion—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.
(Quality in Health Care 2000;9:6–13)
Keywords: audit instrument; nursing care plans; quality
assurance
The patient record is a principal source of
information in which the nursing documenta-
tion of patient care is an essential part.
Traditionally, nurses have written down their
performance of the medical interventions or
observations ordered by the physician. The
rationale behind this was to show that the
instructions had been adhered to and to inform
other nurses or physicians.
Recently, the nursing profession has moved
towards a more independent practice with a
clear recognition of nursing care. With increas-
ing recognition of these nursing components
the documentation of nursing care must
include not only timely and accurate recording
of the performed interventions—medical and
nursing—but also the decision process, ex-
plaining and evaluating why a specific nursing
action was chosen.
In 1967, Yura and Walsh first described the
nursing process model (fig 1) as a structured,
problem solving approach to nursing practice
and its evaluation.
1
This process originally
contained four steps: assessment, planning,
implementation, and evaluation. In a later ver-
sion, the nursing diagnosis was included. The
nursing process model is a central and widely
accepted concept,
2
both for nursing practice
and documentation. The nursing process
model is based on the scientific approach of
investigation and goal oriented action. The pri-
mary purpose of the model is to relate
individualised nursing care to the individual
patient rather than generalised care based on
routines.
The nursing care plan is an essential tool in
the delivery of modern nursing care. The care
plan is a document containing the three
nuclear parts of the nursing process model: a
nursing diagnosis, describing the problem or
need; the aim of the nursing care; and the
interventions that have been planned to achieve
the aim. The purpose of the nursing care plan
is to have a reference easily accessible in the
clinical setting that describes the patient’s
needs and wishes and the nursing interventions
Quality in Health Care 2000;9:6–136
Division of Nur sing
Research at Karolinska
Hospital, Department
of Nursing, Karolinska
Institutet, Stockholm,
Sweden
C Björvell, PhD student,
registered nurse
I Thorell-Ekstrand, senior
lecturer
R Wredling, associate
professor
Correspondence to:
C Björvell
Email:
catrin.bjorvell@medks.ki.se
Accepted 13 December 1999
Page 1
that have been planned for the patient. It is
used to ascertain the continuity of care among
caregivers. The nursing care plan is part of the
permanent patient record.
Since 1980, major health related organisa-
tions and some western countries have begun
to develop standards, laws, and regulations
stating that the nursing process should be
included with nursing documentation. The
World Health Organisation,
3
the International
Council of Nursing,
4
the American Joint Com-
mission on Accreditation of Hospital Nursing
Service Standards,
5
and the United Kingdom
Central Council
6
all promoted the use of the
nursing process in nursing care. The Swedish
law on this subject was passed in 1986,
7
and
was further clarified specifically for nursing by
the National Board of Health and Welfare in
1993 (box 1).
The development of written care plans has
been slow, however, and in Sweden nurses have
only recently started to produce a more struc-
tured documentation of nursing. Nurses con-
tinue to document care retrospectively rather
than document prospective care. Ehnfors
showed in 1993 that 90% of the audited patient
records lacked identified nursing problems,
goals, and nursing discharge notes.
9
In two
thirds of the records, planned interventions
were not stated. In 1996, Nordström and Gar-
dulf stated that the nursing assessment was
insuYciently described in 60% of records
10
;
only 10% contained identified nursing prob-
lems and goals; and less than 45% of the
records contained planned nursing interven-
tions. Even in 1999 Ehnfors and Ehrenberg
showed that only one of 120 patient records
contained a comprehensive description of a
patient problem, as prescribed by Swedish
law.
11
Benefits of documentation
The main benefit of the documentation is
improvement of the structured communication
between healthcare professionals to ensure the
continuity of individually planned patient care.
Without an individualised care plan, nursing
care tends to become fragmentary and based
predominantly on institutional routine and
schedules. The care plan defines the focus of
nursing care not only to the nursing staV but
also to the patient and his relatives.
12
By docu-
menting the agreement between patient and
nurse, an opportunity is provided for the
patient to participate in the decision making
about his own care.
13 14
Moreover, the docu-
mentation of expert nursing provides an
important source of knowledge to the novice
nurse and a potential instigation of the further
development of nursing theory.
2
The care plan
yields criteria for reviewing and evaluating
care, financial reimbursement,
12
and staYng.
Furthermore, a correlation between care plans
and positive patient outcomes, such as a
reduced stay in hospital, has been described.
15
Documentation model
In 1992, a new documentation model was
developed and tested by Ehnfors, Thorell-
Ekstrand, and Ehrenberg.
16 17
The model is
called VIPS, an acronym formed from the
Swedish words for wellbeing, integrity, preven-
tion, and security, which are seen as the major
goals of nursing care (fig 2). This model is
Assessment
Diagnosis and goal
Planned interventions
Implementation
Evaluation
Figure 1 The nursing
process model.
Nursing
history
• Reason for contact
• Health history
Care in progress
• Hypersensitivity
• Social history
Service
• Lifestyle
General
information
• Information
source
• Significant other
Temporary
information
• Confidentiality
• Primary nurse
• Incidental/
progress notes
Nursing
status
Nursing
diagnoses
Nursing
goals
• Communication
• Knowledge/developement
• Breathing/circulation
• Nutrition
• Elimination
• Skin/tissues
Wound
• Activity
• Sleep
• Pain/perceptions
• Sexuality/reproduction
• Psychosocial
Emotions
Relations
• Spiritual/cultural
• Wellbeing
• Composite assessment
Medications
Nursing
interventions
Nursing
outcome
Planned - implemented
• Participation
• Information/education
• Support
• Environment
• General care
Advanced care
Training
• Observation/
monitoring
• Special care
Wound care
• Drug handling
• Coordination
Coordinated care
planning
Discharge planning
Medical information
• Medical assessment
Discharge
notes
Figure 2 Flow diagram of the VIPS model for nursing documentation. Reproduced from Ehrenberg et at
17
with permission.
Regulations about nursing
documentation
“The patient record shall include a distinct
and clear nursing documentation. The
nursing documentation shall, from the
patient’s individual needs, describe the
planning, implementation and eVects of the
nursing care. The documentation shall be
designed in such a way that it contributes to
secure patient safety and provides a basis for
continuous evaluation and revision of nurs-
ing interventions. The nursing care shall be
summarised in a patient discharge note at
the time of discharge.
8
(Authors’ transla-
tion.)
Box 1 Regulations about nursing documentation as
stipulated by the Swedish National Board of Health and
Welfare
Development of an audit instrument for nursing care 7
Page 2
designed to be used in the documentation of
the nursing process and therefore includes a
nursing care plan. The model also includes a
nursing discharge note. The purpose of the
model is to guide the nurse in the sequences of
assessment, problem identification, aim, plan-
ning of interventions, implementation, and
evaluation of results and thereby to make nurs-
ing documentation structured, adequate, and
easy to use in clinical care.
In the VIPS model, 13 keywords are used for
classifying the information collected by the
nurse about the patient’s situation and status
into categories, for example communication,
nutrition, and psychosocial status. Ten key-
words classify the nursing interventions into
categories such as information, support, and
environment. The use of keywords simplifies
information retrieval, although, to retrieve the
information asked for, a consensus about defi-
nitions of categories must be reached.
18
The
VIPS model provides such a lexicon, in which
each category, labelled by a keyword, has a
definition, a description, and prototypical
examples given in a manual. Keywords may be
seen as a first step towards a unified nursing
language for patient care.
The VIPS model has been received with
interest and appreciation by nurses in Sweden
and is now the most commonly taught and
used model for nursing documentation in hos-
pitals and primary health care.
17
Auditing patient records
Audit has to be distinguished from traditional
review (box 2). The audit of patient records
may be done for several reasons. The most
common reason is because the audit is part of
an ongoing process of quality improvement. A
clinic may have agreed to document in a
certain way, possibly with a minimum data set
as a standard, or wants to evaluate specific cri-
teria for quality health care.
19–21
Evidence exists that a continuously per-
formed audit of patient records, combined with
discussions about improvements, is one way to
improve the quality of the records and to
change certain behaviours of healthcare
professionals.
22–24
Another benefit of auditing
documentation is that it makes comparisons
possible over time and among wards or hospi-
tals, provided that a reliable audit instrument is
used to put a numerical value on the written
content.
25 26
Audit is also used to evaluate the
eVects of quality management
27
by identifying
the necessary professional strengths and the
weaknesses that need to be addressed and cor-
rected. Craig reports that nurses using her
audit tool acquired a better understanding of
what was expected of them for recording of
care and patient care itself, and also focused on
the areas that they specifically needed to
concentrate for improvement.
28
It is important to diVerentiate between
auditing records for the sake of measuring the
quality of record keeping and auditing records
for the sake of measuring the quality of given
care. There is important criticism in the litera-
ture about the auditing of patient records for
the purpose of checking patient care, the argu-
ment being that patient records do not
necessarily reflect the reality of the given
care.
29 30
This raises the question whether it is
possible to claim that audit measures the qual-
ity of care. Whether better documentation can
also influence and improve patient care is
another question, not dealt with in this article.
Well written records, however, may be seen as a
step towards a process of quality assurance, as
a structured element in the nursing care. Don-
abedian is careful to stress that good structure
only increases the likelihood of a good process
in the actual care given and that the correlation
between process and outcome has yet to be
shown.
31
Two Swedish audit instruments have been
developed earlier, one by Ehnfors
9
and the
other one by Gardulf and Nordström.
10
Both
instruments are based on the nursing process
and evaluate the record in its quantitative
aspect; is there documentation for each func-
tion or is there not? In addition, Ehnfors evalu-
ates, for each patient problem, the flow of
information in accordance with the nursing
process. Consequently, neither of the instru-
ments includes a qualitative evaluation of the
written content in the sense of the amount of
information, wording, pertinence, etc. Several
other audit instruments described in inter-
national journals
29 32–36
were also inadequate
with regard to the quality and quantity aspects
of auditing.
Improving nursing documentation is an
urgent issue. Poor documentation is an indica-
tion that further investigation is needed to
judge whether or not the given care is less than
optimal. Audit instruments for nursing records
are therefore needed to identify poor assess-
ment, poor structure, and the lack of a plan for
the patient’s care. They are also needed for
evaluating the eVects of interventions aimed to
improve the documentation.
The aims of this study were to develop an
audit tool to measure both the quantitative and
the qualitative aspects of nursing documenta-
tion, based on the VIPS model, and to evaluate
the validity and reliability of that tool.
Methods
DEVELOPMENT OF THE INSTRUMENT
Before the instrument was constructed by two
of the authors (CB, IT-E), a set of criteria was
identified to determine what questions needed
to be answered about nursing documentation
“DiVerences between audit and traditional
review:
x Use of explicit criteria for measurement
rather than implicit judgments
x Numerical comparison of current prac-
tice patterns against these criteria
x Formal identification of action required
to resolve any discrepancies disclosed
x Recording the process to retain infor-
mation and increase impact of audit on
future management.
19
Box 2 The diVerence between audit and review
8 Björvell, Thorell-Ekstrand, Wredling
Page 3
in the patient record. These criteria were
derived from the following sources:
x The Swedish law that stipulates that nursing
documentation should include the steps of
the nursing process as described above, the
signing and dating of each entry, a minimum
degree of legibility, and a nursing discharge
note
x The VIPS model which includes the nursing
process, the use of specified keywords, the
correct classification of the keywords in
accordance with the user manual, and a
nursing discharge note
x Common hospital policies that prescribe
that each patient should have a named nurse
with the primary responsibility for the
patient’s nursing care and care plan docu-
mentation.
At this stage, 19 questions were formulated
to determine whether this information was
documented in the patient record. Each
question was constructed to reveal both the
quantity and the quality of the written content
on a rating scale. A manual was designed to
explain how to score each question.
The quality and quantity values were scored
on a rating scale from zero to three, zero indi-
cating “poor” and three indicating “very
good”. The quantity value is expected to meas-
ure whether or not there is a written note and,
if so, how much is written. For example, for the
patient’s nursing status, a certain minimum
number of nursing areas, represented by
keywords in the VIPS model and relevant to
surgical care, should be described for a patient
in a surgical ward. The quality value is used to
measure to what degree the written notes are
clear and concise, without superfluous text,
and include all relevant nursing information
with a correct use of language. If all notes fulfil
these criteria, a full score of three is given; if
more than 50% of the notes, but not all of
them, fulfil the criteria, a score of two is given;
if less than 50% fulfil the criteria, though some
notes still fulfil the criteria, a score of one is
given, etc. Furthermore, the instrument is
expected to measure the extent to which it is
possible to follow a patient problem through
the nursing process. That is, whether the prob-
lem is properly assessed and described in a
diagnosis, with the expected outcome, planned
and implemented interventions, and an evalua-
tion. The instrument was named Cat-ch-Ing.
To test usability for understanding questions
and phrasing of the instrument, five patient
records collected from one hospital ward were
independently reviewed by three nurses using
the new instrument. The instrument was
revised after each of the three audits. The revi-
sions concerned the clarification of definitions
in the manual and the deletion or rephrasing of
questions. Two questions were omitted, one
about the evaluation of nursing care, which was
already covered by other questions, and the
other about the use of keywords other than
those stipulated by the VIPS model. One ques-
tion about the discharge note was rephrased.
TESTING OF RELIABILITY AND VALIDITY
Inter-rater reliability was tested by comparing
diVerent reviewers’ total Cat-ch-Ing scores
given to the same record. Twenty patient
records from each of three hospital wards at a
university hospital in Stockholm, Sweden were
used for this part of the development. The
records were selected from the registers of the
wards and were coded to protect patient iden-
tity. The specialty wards were surgery, neurol-
ogy, and rehabilitation. The criteria for the col-
lection of the records were that they should
concern the first 20 patients from each ward
who were admitted for five days or more during
a specific time period. The collected records
were audited three times, each time by a diVer-
ent reviewer. The auditors were nurses know-
ledgeable and experienced in nursing docu-
mentation and in the use of the VIPS model.
Before the audit, a calibrating process was
undertaken, which means that the use of the
instrument was taught and discussed with the
reviewers.
The inter-rater reliability was statistically
investigated by calculating the inter-rater reli-
ability coeYcient
37
between raters’ total scores
of each record. Additionally, score diVerences
between reviewers, on each question in the
same patient record, were compared and
calculated as percentages of agreement.
The content-validity ratio was calculated as a
means of quantifying the degree of consensus
in a panel of 10 experts, who made judgments
about the instrument’s content validity. Each
expert was asked to judge whether or not the
10 questions in the instrument, meant to
measure the nursing process, were indeed
essential in measuring the parts of the nursing
process documented in a patient record. The
method, developed by Lawshe,
38
is described
by the formula:
where CVR is the content-validity ratio, ne is
the number of panellists indicating “essential”
about a specific question and N is the total
number of panellists.
The criterion-related validity was estimated
by the degree of correlation between the score
of the Cat-ch-Ing instrument and the score of
the audit instrument developed by Ehnfors
9
and used in previous research. The Ehnfors
instrument was constructed to measure
whether each part of the nursing process (and
thereby also the VIPS model) was documented
for each nursing problem identified in the
patient record. The nursing process was the
chosen criterion in both the Ehnfors and the
Cat-ch-Ing instrument. The Ehnfors instru-
ment has a score from zero to five, giving one
point for each documented part of the nursing
process: assessment, goal and diagnosis,
planned intervention, implemented interven-
tion, and a discharge note, concerning each
specified nursing problem. The Ehnfors instru-
ment scores mainly the quantity; the quality
aspect is only present for evaluating the flow of
Development of an audit instrument for nursing care 9
Page 4
information in the nursing process for each
patient problem.
A mean Ehnfors score of all identified nurs-
ing problems in a record was calculated and
compared with the total score given by the
Cat-ch-Ing instrument for the same record.
The results were then tested by the use of
Pearson’s correlation coeYcient.
The research protocol was approved by the
regional ethical committee of the Karolinska
Institutet.
Results
The final version of the Cat-ch-Ing instrument
(appendix), which was completed in December
1996, consists of 17 questions: 10 reflecting the
presence of each step of the nursing process;
four about dating, signatures, and legibility;
one about keywords; and one asking about the
existence of the individual patient’s named
nurse.
SCORING
The total score ranges from zero to 80 points.
Sixty eight per cent of the total score may be
achieved by questions that are posed to
measure the content of the nursing process;
15% relate to questions that judge legibility,
signing, and dating; 7% correspond to key-
words; 5% to the nursing discharge note; and
5% to the identification of a primary nurse.
Nine of the questions may be rated for quan-
tity and quality. Five questions can be rated
only for quantity, for example “are all entries
signed?”, and one question about legibility is
rated only for quality. The two remaining
questions have “yes” or “no” answers (fig 3).
The inter-rater reliability coeYcients were
calculated to be 0.98, 0.98, and 0.92 for each
group of patient records from the three wards.
The content validity ratio between the expert
panellists (table 1) ranged between 0.20 and
1.0. Of the 12 items measuring the nursing
process in the instrument, all but three were
judged to be essential by the expert panellists.
The criterion related validity for the Cat-ch-
Ing instrument was illustrated by the signifi-
cant correlation (r = 0.68, p = <0.0001, 95%
CI 0.57 to 0.76) between the scores of the
Ehnfors and the Cat-ch-Ing instruments (fig
4).
On examining the score diVerences between
the three reviewers on each question (n=4680
comparisons) we found no diVerences in scores
in 64% of the comparisons. Thirty two per cent
of the comparisons diVered by one point and
4% diVered by two or three points. The largest
score diVerences (two or three points) occurred
on the items of qualitative judgment of nursing
assessment and nursing interventions. Larger
records (for example, 56 pages of text) had a
greater discrepancy among raters scoring the
same record than less extensive records.
Discussion
This study has resulted in a new instrument for
auditing nursing documentation of the patient
record. The instrument has proved to be valid
for measuring information pertinent to the
nursing process, and to possess a high degree of
reliability when used by diVerent auditors.
In the few records in which an increased dis-
crepancy among auditors was noted, the
patient records proved to be comprehensive.
The reasons for the discrepancy may be that it
Is there a nursing history?
Is there a patient status:
On arrival?
Updated?
At discharge?
Is there a nursing care plan:
Nursing diagnosis?
Expected outcome?
Interventions:
Planned?
Implemented?
Is the underlying information
for nursing diagnosis described
in the nursing status?
Is the nursing outcome described?
Explanation of the interpretation of given scores
The box describes the questions in the instrument that reflect the nursing
process, with the shaded area encompassing the parts adherent to the
nursing care plan. The scores for quantity and quality about the care plan
show that, for this patient, there were few, but still some, planned nursing
interventions documented (quantity = 1). Those that were documented
had excellent quality (quality = 3). However, there is no description at all
of analysis of the patient problem (nursing diagnosis) or the aim of the
care that supposedly led the nurse to her choice of intervention.
Quantity: 3
Quantity: 2
Quantity: 2
Quantity: 3
Quantity: 0
Quantity: 0
Quantity: 1
Quantity: 2
Quantity: 0
Quantity: 3
Quality: 1
Quality: 2
Quality: 1
Quality: 2
Quality: 0
Quality: 0
Quality: 3
Quality: 2
Figure 3 Example of scoring in an audit of one patient record.
Table 1 Content validity ratio between expert panellists judging items of the instrument as
essential or not in measuring the nursing process in the patient record
Item
Judged as “essential”
by experts (n=10) Ratio
Is there a nursing history? 9/10 0.80
Is there a nursing status:
On arrival? 10/10 1.0
Updated? 9/10 0.80
On discharge? 8/10 0.60
Is there a nursing care plan:
Nursing diagnosis? 10/10 1.0
Expected outcome? 7/10 0.40
Interventions:
Planned? 9/10 0.80
Implemented? 9/10 0.80
Is the underlying information for the nursing diagnosis described
in the nursing status?
6/10 0.20
Is the nursing outcome described? 9/10 0.80
5
4.5
3
4
2.5
2
1.5
1
0.5
0
_
0.5
3.5
Ehnfors score
10 20 30 40 50 60 70 80
Cat-ch-Ing score
Figure 4 Correlation between the Ehnfors audit instrument
and the Cat-ch-Ing audit instrument for nursing
documentation, r = 0.68, p <0.0001, 95% CI 0.57 to
0.76.
10 Björvell, Thorell-Ekstrand, Wredling
Page 5
is harder to keep track of pertinent information
in a large mass of nurses’ notes, or simply that
the auditor loses concentration after reading
the same record over a long period.
The Cat-ch-Ing instrument has been thor-
oughly investigated for validity and reliability.
Two types of validity have been confirmed, and
using three reviewers in the reliability testing
strengthens the results. The Cat-ch-Ing instru-
ment showed a strong validity for measuring
whether the nursing process existed in the
patient record, which is one of the main
strengths of the instrument. It clearly gives a
measure not only of the amount of written text
but also, most importantly, of the quality of the
information that has been documented. Fur-
thermore, the Cat-ch-Ing is only a one page
instrument with a two page manual, whereas
other instruments usually have more extensive
instructions, and this may be a facilitating
factor.
Various limitations to the study should be
highlighted, however. Firstly, the auditors were
selected because of their knowledge and
experience in documentation, as well as in
nursing. This was thought to be a necessary
prerequisite when developing a new instru-
ment. We have not tested the instrument
among nurses in general. Secondly, the study
dealt with records from the wards of a major
university hospital that provides somatic acute
care and short term rehabilitation. The testing
we did could be considered valid for this type of
record only. Thirdly, the weighting of the scores
between the various questions may have to be
adjusted; as much as 32% of the score can be
achieved by dating and signing correctly, by
recording the named nurse, by using a
typewriter, and by using the keywords of the
VIPS model correctly. None of this indicates
the nursing process.
The development and testing of the Nord-
ström and Gardulf audit instrument for
nursing documentation has not been scientifi-
cally described in the literature. The Phaneuf
Nursing Audit tool has been described in
numerous papers. Neither of these produces a
clear result of validation and reliability testing.
Also, the Phaneuf instrument claims to meas-
ure the quality of care by auditing the patient
record and has received criticism for this.
29 32 36
The Ehnfors instrument,
9
used as a compari-
son in this study, has an obvious, high, face
validity and inter-rater reliability when tested
by Kohen’s ê (ê = 0.93).
Group level comparisons with inter-rater
reliability coeYcients in the vicinity of 0.70
show suYcient reliability.
39
Thereby the reli-
ability of the Cat-ch-Ing instrument, with a
coeYcient of 0.98, proved to be very satisfac-
tory. It is a known problem that auditing
patient records involves subjective judgments.
39
Less inference is required of the auditor when
reviewing the documentation of demographic
information compared with that required when
assessing the adequacy of documentation
related to the patient specific needs and specific
nursing skills, such as educational strategies
and information giving.
40
According to Lawshe,
38
the minimum value
of the content validity ratio to ensure that
agreement is unlikely to be due to chance, with
10 panellists, is 0.62 per identified item. This
indicates that the Cat-ch-Ing instrument to a
large degree measures the documented nursing
process in the patient record, as intended.
Seven out of 10 items in the instrument
received satisfactory values. The three items
that received a lower value will be considered
for exclusion. The reasons for the lower value
for the questions, “is the underlying infor-
mation for the nursing diagnosis described in
the nursing status?” and “is there a new nursing
status at the time of discharge?”, may be
because the questions were thought to be
already covered by other questions in the
instrument. Why a lower value was given to the
question, “is the expected outcome (goal)
documented in the care plan?” is more diYcult
to explain. One reason may be that the expert
panellists all work with the nursing process
model in a theoretical setting where the patient
outcome is not an explicit part of the model,
whereas in the practical setting it is an explicit
part of the model.
The fact that yet another nursing audit
instrument has been developed and tested
implies to nurses that the auditing of nursing
performance is an important subject, possibly
making more nurses familiar with auditing and
quality improvement. One approach to increas-
ing the awareness and knowledge of the audit-
ing of nursing documentation and care plan-
ning is to encourage the use of a peer review
system. By using an instrument like the
Cat-ch-Ing, peer review of patient records may
be a means not only of improving patient
records but also of instigating a discussion and
thereby possibly reaching a consensus on best
nursing care in specific situations, which may
improve direct care.
The criterion based audit is a concept used
in medicine
8
which may be applicable to nurs-
ing also. In this study, the nursing process was
used as the evaluated criterion because this is
what Swedish law prescribes, and may be seen
as the short term goal—to improve nursing
documentation and record keeping. However,
the Cat-ch-Ing instrument is constructed so
that it could be modified to measure specific
criteria of nursing care quality, as documented
in the patient record. Modification would then
be described in the user manual, for example
what interventions are expected in the nursing
care plan for a patient with a specific problem
to get a full score, or what specific information
will be expected under the keyword of
nutrition for a patient with newly discovered
diabetes in order to get a full score. This may
be seen as a long term goal of auditing within
nursing care.
Conclusion
It can be concluded that the Cat-ch-Ing
instrument proved to be a valid and reliable
audit instrument for nursing documentation
in patient records when the VIPS model was
used as the basis of the documentation. Nurs-
ing, as a growing scientific discipline, is
Development of an audit instrument for nursing care 11
Page 6
constantly adding new knowledge to clinical
care and thereby increasing the need to be able
to detect whether patient care was docu-
mented in accordance with scientific findings.
The next step, once record keeping is
improved, will be to evaluate the eVect that it
has on patient care.
We are grateful to the Stockholm County Council, whose gen-
erous grant made this study possible. We also thank Anders
Sjöberg for statistical advice.
1 Yura H, Walsh M. The nursing process. Assessing, planning,
implementing, evaluating. 5th edition. Norwalk, CT: Apple-
ton & Lange, 1988.
2 Meleis A. Theoretical thinking: development and progress. 2nd
edition. Philadelphia: Lippincott Company, 1991.
3 World Health Organisation. Nursing process workbook.
Copenhagen: WHO Regional OYce for Europe, 1982.
4 Clark J. An international classification for nursing practice.
In: Bakken S, Holzemer W, Tallberg M, et al, editors.
Informatics: the infrastructure for quality assessment improve-
ment in nursing. Proceedings of the 5th international nursing
informatics symposium post-conference; 1994 June 24–25;
Austin, Texas. San Francisco: UC Nursing Press, 1994.
5 Joint Commission on Accreditation of Healthcare Organiza-
tions. Accreditation manuals for hospitals. Nursing Care Stand-
ards. Outbrook Terrace: The Commission, 1991.
6 The United Kingdom Central Council for Nursing,
Midwifery and Healthvisiting. Standards for records and
record keeping. London: The United Kingdom Central
Council for Nursing, Midwifery and Healthvisiting, 1993.
7 Svensk författningssamling. 1985:562 Patientjournallagen.
Stockholm: Liber Allmänna förlaget; 1985. (Swedish law on
patient record keeping.)
8 Socialstyrelsen. Föreskrifter och allmänna råd i omvårdnad
inom hälso- och sjukvården. SOSFS 1993:17. Stockholm:
Socialstyrelsen; 1993. (Swedish National Board of Health
and Welfare.)
9 Ehnfors M. Nursing care as documented in patient records.
Scand J Caring Sci 1993;7:209–20.
10 Nordström G, Gardulf A. Nursing documentation in
patient records. Scand J Caring Sci 1996;10:27–33.
11 Ehrenberg A, Ehnfors M. Patient problems, needs and
nursing diagnoses in Swedish nursing home records. Nurs
Diag 1999;10:65–76.
12 Carpenito LJ. Nursing diagnosis. Application to clinical
practice. 7th edition. Philadelphia: Lippincott Company,
1997.
13 Jairath N. Strategies for motivating CCU patients. Dimens
Cr it Care Nurs 1994;13:324–33.
14 Kramer M. Nursing care plans. Power to the patient. J Nurs
Adm 1972;Sept-Oct:29–34.
Record #:
Date:
Read the User Manual carefully
* = see the User Manual.
Scores within brackets.
Is there a primary nurse indicated?
Is there a nursing history?
Is there a nursing status:
On arrival?
Updated?*
At discharge?
Is there a nursing care plan:
Nursing diagnosis?*
Expected outcome?*
Interventions:
Planned?
Implemented?
Is the underlying information for the
nursing disgnosis described in nursing status?
Is nursing outcome described?*
Are the VIPS keywords used?*
(regarding history, status, interventions)
Is there a nursing discharge note?
Are all entries dated (year, month, day)?
Are all entries signed?
Is there a clarification of signature?
Is the record legible?*
no
only by surname
by surname and christian name
(0)
(2)
(4)
Ward:
Reviewer:
Hospital:
Quantity*
Complete = (3)
Partly = (2)
Occasional = (1)
None = (0)
Quality*
Very good = (3)
Good = (2)
Less good = (1)
Poor = (0)
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity:
Quantity:
Quantity: Quality:
Quantity: Quality:
Yes (4) No (0)
Quantity:
Quantity:
Quantity:
Quality:
Total score: (max 80)
Appendix
12 Björvell, Thorell-Ekstrand, Wredling
Page 7
15 Black S, Taunton R, Thomas J, et al. Evaluation of a scale to
assess nurses’ attitudes towards written care plans. Appl
Nurs Res 1989;2:92–5.
16 Ehnfors M, Thorell-Ekstrand I, Ehrenberg A. Towards
basic nursing information in patient records. Vard i Norden
1991;21:12–31.
17 Ehrenberg A, Ehnfors M, Thorell-Ekstrand I. Nursing
documentation in patient records: experience of the use of
the VIPS-model. J Adv Nurs 1996;24:853–67.
18 Grobe J, Hughs C. The conceptual validity of a taxonomy of
nursing interventions. J Adv Nurs 1993;18:1942–61.
19 Shaw C. Criterion based audit. BMJ 1990;300:649–51.
20 GriYths J, Hutchings W. The wider implication of an audit
of care plan documentation. J Clin Nurs 1999;8:57–65.
21 Honnas R, Zlotnick C. Quality improvement in action:
development of a tool. J Nurs Care Qual 1995;9:72–7.
22 Mashru M, Lant A. Inter-practice audit of diagnosis and
management of hypertension in primary care: educational
intervention and review of medical records. BMJ 1997;314:
942.
23 Gabbay J, McNicol M, Spiby J, et al. What did audit
achieve? Lessons from preliminary evaluation of a year’s
medical audit. BMJ 1990;301:526–9.
24 Heath D. Random review of hospital patient records BMJ
1990;300:651–2.
25 Hansebo G, Kihlgren M, Ljunggren G. Review of nursing
documentation in nursing home wards - changes after inter-
vention for individualised care. J Adv Nurs 1999;29:1462–
73.
26 Fagrell B, Funcke L, Nyberg K. Nursing documentation
according to the VIPS-model at nursing home. Vard i
Norden 1998;18:40–5.
27 Webb C, Pontin D. Evaluating the introduction of primary
nursing: the use of a care plan audit. J Clin Nurs
1997;6:395–401.
28 Craig D. Audit design. Recent Advances in Nursing 1987;17:
65–93.
29 Sparrow S, Robinson J. The use and limitations of
Phaneuf’s nursing audit. J Adv Nurs 1992;17:1479–88.
30 McElroy A, Corben V, McLeish K. Developing care plan
documentation: an action research project. J Nurs Manage
1995;3:193–9.
31 Donabedian A. The quality of care. how can it be assessed?
JAMA 1988;260:1743–8.
32 Manfredi C. Reliability and validity of the Phaneuf Nursing
Audit. WJNR 1986;8:168–80.
33 Goldstone L, Ball J, Collier M. Monitor: an index of the qual-
ity of nursing care for acute medical and surgical wards.
Newcastle upon Tyne: Newcastle upon Tyne Polytechnic
Products, 1983.
34 Harvey G. An evaluation of approaches to assessing the
quality of nursing care using (predetermined) quality assur-
ance tools. J Adv Nurs 1991;16:277–86.
35 Vandelt M, Ager J. Quality patient care scale. New York:
Appleton-Century-Crofts, 1974.
36 Ventura M. Correlation between the quality patient care
scale and the Phaneuf Audit. IntJNursStud1980;17:155–
62.
37 Winer, B. Statistical principles in experimental design. 2nd edi-
tion. London: McGraw-Hill, 1971.
38 Lawshe C.H. A quantitative approach to content validity.
Personnel Psychology 1975;28:563–75.
39 Polit D, Hungler B. Nursing research. principles and methods.
5th edition. Philadelphia: Lippincott, 1995.
40 Edwards N, Pickard L, van Berkel C. Community health
nursing audit: issues encountered during the selection and
application of an audit instrument. Public Health Nursing
1991;8:3–9.
Development of an audit instrument for nursing care 13
Page 8
    • "One option for ensuring management continuity of care is to rely on patient information in the medical record; especially in the written discharge summary forms or letters which are the most common information source at discharge [7]. Such documentation influences the understanding and action at the next level of care [8]. In such one-direction information meta-communication – i.e. communication about the communication such as clarifying questions – is often lacking. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Handovers between hospital and primary healthcare possess a risk for patient care. It has been suggested that the exchange of a comprehensive medical record containing both medical and patient-centered aspects of information can support high quality handovers. Objective: The objective of this study was to explore patient handovers between primary and secondary care by assessing the levels of patient-centeredness of medical records used for communication between care settings and by assessing continuity of patient care. Methods: Quantitative content analysis was used to analyze the 76 medical records of 22Swedish patients with chronic diseases and/or polypharmacy. Results: The levels of patient-centeredness documented in handover records were assessed as poor, especially in regards to informing patients and achieving a shared understanding/agreement about their treatment plans. The follow up of patients’ medical and care needs were remotely related to the discharge information sent from the hospital to the primary care providers, or to the hospital provider’s request for patient follow-up in primary healthcare. Link to full-text paper, available until April 28 2015: http://authors.elsevier.com/a/1Qg5-_VXePTrDi
    No preview · Article · Jan 2015 · International Journal of Medical Informatics
  • Source
    • "The nursing process is a structured problem-solving approach to nursing practice and education and was first explained by Yura and Walsh in 1967. It originally comprised of four stages: assessment, planning, implementation and evaluation of care and lately included nursing problem or diagnosis (Bjö rvell et al. 2000). The nursing process model has been widely used as a theoretical basis for nursing practice and documentation. "
    [Show abstract] [Hide abstract] ABSTRACT: This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation. Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings. Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010. A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted. Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality. Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.
    Full-text · Article · Apr 2011 · Journal of Advanced Nursing
  • Source
    • "[4,10,13,47–51]. In this study, the evaluation of nursing care plans was carried out using quantitative criteria based on the quantitative part of the Catch-Ing©audit instrument [48], since this part of the instrument measures how the different phases in the nursing process are documented. The instrument was modified for this purpose because the Cat-ch-Ing©audit instrument measures only the presence or absence of the phase of nursing process and does not measure the use of nursing classifications and the relationships between classifications. "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose: The purpose of this study was to describe and evaluate whether nurses have documented patient care in compliance with the national nursing documentation model in electronic health records, which means the use of the nursing process and the use of standardized terminology in different phases of the nursing process. Methods: The data were collected from a central hospital in 2003-2006. The data consist of the electronic nursing care plans of 67 neurological patients and 422 surgical patients. The data were analyzed using statistical methods and content analysis. Results: Standardized electronic nursing documentation is based on the nursing process, although the use of the nursing process varies across patients. There is a lack of progress notes relating to needs assessment, the identification of nursing diagnoses and care aims, and the nursing interventions planned in the documentation. The standardized terminology is used in the documentation but inconsistencies emerge in the use of the different classifications. Conclusion: The national model for electronic nursing documentation is suitable for the documentation of patient care in nursing care plans. However, health care professionals need further training in documenting patient care according to the nursing process, and in using the terminology in order to increase patient safety and improve documentation.
    Full-text · Article · May 2010 · International Journal of Medical Informatics
Show more