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

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 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...

Implementering av sykepleiediagnoser i fritekst

“…Søkeord som korresponderer med fasene i sykepleieprosessen, er søkeord på overordnet nivå. For sykepleieanamnese, pasientstatus og sykepleietiltak følger søkeord og undersøkeord (6,12,15 Et granskningsinstrument kan anvendes for å vurdere kvalitet i sykepleiedokumentasjonen (7,16,26,29). Et reliabelt og validert granskningsinstrument gir mulighet for å sammenlikne resultat etter endringer og mellom enheter.…”

“…Spørsmålene i Cat-ch-Ing retter seg mot datasamling, sykepleiediagnose, planlagte tiltak, resultat og utskriving (26,29). (29).…”

“…Tilpasningen må beskrives i brukerveiledningen til instrumentet (29 Også i posttestresultatene er det sykepleieanamnese som har høyest skår. Resultat i posttest for pasientstatus i innkomstnotatet viser en liten nedgang i gjennomsnittsskår.…”

“…granskningsinstrumentet Det vil alltid vaere en viss grad av subjektivitet ved vurdering av sykepleiedokumentasjon (17,26,29). I brukerveiledningen til Cat-ch-Ing er kriterier for vurdering beskrevet.…”

Kan auditredskabet Cat-ch-Ing anvendes til maling af kvaliteten i sygeplejedokumentation baseret pa VIPS-modellen?

“…Den største uoverensstemmelse var på den kvalitative vurdering af sygeplejeanamnese og planlagte sygeplejehandlinger. Indholdsgyldigheden og kriteriegyldigheden blev vurderet som vaerende tilfredsstillende (22 Nilsson & Willman konkluderede, at Cat-ch-Ing var nem at anvende, men praeciserede samtidig, at vurderingen af sygeplejejournalerne rummede en betydelig grad af fortolkning af kriterierne i den tilhørende manual. Forfatterne anbefalede anvendelse af Cat-ch-Ing ved fremtidige journalaudit, men rekommanderede samtidig en videreudvikling af auditredskabet.…”