D-Catch blir norsk

Nøst, Torunn Hatlen; Tettum, Bente I.; Frigstad, Sigrun Aasen; Woldstad, Kristin; Haugan, Berit; Oppheim, Ann Elise; André, Beate; Rotegård, Ann Kristin

doi:10.4220/sykepleiens.2015.54056

Cited by 5 publications

(12 citation statements)

References 7 publications

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“…This is a Norwegian version of the audit instrument Dutch-Catch (D-Catch) that was developed for assessing nursing documentation in hospitals building on the audit instruments Cat-ch-Ing and Scale for Degrees of Accuracy in nursing diagnosis. 24,25,29 The instrument is translated and culturally adjusted to Norwegian legislation and practice according to scientific criteria. 22,24,25 An early version of the instrument has been used in other studies, 9,30 but the updated version has not to our knowledge been applied.…”

Section: Audit Instrumentmentioning

confidence: 99%

“…24,25,29 The instrument is translated and culturally adjusted to Norwegian legislation and practice according to scientific criteria. 22,24,25 An early version of the instrument has been used in other studies, 9,30 but the updated version has not to our knowledge been applied. N-Catch II consists of eight items assessing aspects of both quality and quantity.…”

Section: Audit Instrumentmentioning

confidence: 99%

“…This article reports the impact of the intervention expressed as changes in the EHR assessed with a Norwegian version of the audit instrument D-Catch, 11,12 namely N-Catch II. 22,25…”

Section: Introductionmentioning

confidence: 99%

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Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital

Nøst

Frigstad

André

2016

Nordic Journal of Nursing Research

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Discussions on how nursing documentation should be carried out have been ongoing for the last decade. In this study, free-text format for nursing diagnoses was introduced to nursing staff at a university hospital in Norway. The aim of the study was to investigate the impact of an education intervention introducing nursing diagnoses in a free-text format following a problemetiology-symptom structure. A pretest-posttest design was performed to assess changes in quality and quantity in the nursing documentation using the audit instrument N-Catch II. Several elements in the nursing documentation had statistically significant changes; the largest was found for quantity in nursing diagnoses. Education interventions aimed to improve nurses' documentation in the electronic health record may have an effect on more complete and accurate nursing documentation. The presented education intervention showed a significant impact of more accurate nursing diagnoses and significant improvements in nursing documentation.

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Section: Audit Instrumentmentioning

confidence: 99%

Section: Audit Instrumentmentioning

confidence: 99%

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Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital

Nøst

Frigstad

André

2016

Nordic Journal of Nursing Research

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“…The N-Catch II was culturally adapted and translated into Norwegian (17) from the valid and reliable Dutch D-Catch instrument (11). It is designed to assess electronic written nursing documentation and includes a quantitative (e.g presence of relevant information), and a qualitative (e.g.…”

Section: Criteria Standard and Audit Toolmentioning

confidence: 99%

Improving the Quality of Nursing Documentation at A Residential Care Home: A Clinical Audit

Moldskred¹,

Snibsøer

2020

Preprint

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Background: Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice.Methods: A criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0 - 3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019. Results: None of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95% confidence interval 0.3 - 0.6) for “aims for nursing care” to 1.1 (0.9 - 1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8 - 1.1) for “evaluation/progress reports” to 1.9 (1.5 - 2.2) for “nursing assessment on admission”.Conclusions: A criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.

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“…granskningsinstrument for vurdering av sykepleiedokumentasjon, N-Catch II. Dette er et instrument som er oversatt og tilpasset norske forhold (11). Det har sitt utgangspunkt i D-Catch, et internasjonalt granskningsinstrument for sykepleiedokumentasjon (12).…”

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