This study aimed to evaluate the longitudinal effects of a nursing-documentation intervention on the quantity and quality of the nursing documentation in a sample of patient records at a university hospital in Stockholm, Sweden. In this quasi-experimental longitudinal study, two hospital wards participated in a 2-year intervention and a third ward was used for comparison. The intervention consisted of organizational changes and education regarding nursing documentation in accordance with the VIPS model, a model designed to structure nursing documentation. To evaluate the effect, patient records were audited at three different time points: before the intervention, directly after the intervention and 3 years after the intervention. A total of 269 patient records were used. The findings showed a significant score increase in quantity as well as in quality of the nursing documentation, in the intervention wards directly after the intervention, as compared with those from the comparison ward. The results suggests that a comprehensive intervention based on the VIPS model and including organizational support for registered nurses (RN) may improve nursing documentation in an acute care hospital setting.

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 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.) Methods-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 coeYcient. 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 coeYcient. The patient record is a principal source of information in which the nursing documentation 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. Results-TheRecently, the nursing profession has moved towards a more independent practice with a clear recognition of nursing care. With increasing 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, explaining 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 version, 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 primary 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 be...

A number of issues debated among the participants in this study could be seen as organizational matters and lead to the important issue of multidisciplinary and organizational work when implementing innovations within nursing.

The present findings suggest that the incentives to use nursing diagnoses originate from effects generated from performing a deeper analysis of the patient's nursing needs. Further research is needed to test and validate the usability and consequences of using nursing diagnoses in clinical practice. Motivating factors found in this study may be valuable to Registered Nurses for the use and development of nursing diagnoses in clinical care. Moreover, these factors may be of relevance in other countries that are in a similar situation as Sweden concerning application of nursing diagnoses.

Laparoscopic cholecystectomy patients in both groups recover equally well, indicating that a greater proportion of LC patients should be offered the outpatient modality.

The Cat-ch-Ing EPI instrument shows a high reliability and validity as an audit instrument to evaluate the content of nursing discharge notes.

The QANDAC instrument may be a useful audit tool for quality improvement and research in aged care documentation.

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