The quality of assessment of patients with chest pain: the development of a questionnaire to audit the nursing assessment record of patients with chest pain

Abstract

The quality of nursing and medical records has been a source of concern for many years (Audit Commission 1995). This study has two main purposes: firstly, to design an audit questionnaire to evaluate the quality of nursing assessment records of patients with chest pain; and secondly, to make some tentative conclusions about the quality of nursing assessment of patients with a chest pain in order to pinpoint areas that need further study. A sample of 30 patients was selected for this study on the basis of some well-defined inclusion criteria. The nursing assessment notes of these patients were evaluated using the audit questionnaire. It was found that the questionnaire was effective in gleaning appropriate information from the nursing notes to be able to derive some tentative conclusions about the quality of nursing assessment of patients with chest pain, i.e., on the whole nursing assessment was found to be superficially carried out, potentially making errors of omission and commission likely to occur. The inter-rater reliability of the questionnaire was found to be good. The questionnaire also seems to measure what it purports to measure (i.e. has content validity). However, this needs to be further checked by using a larger sample.

Desarrollo y validación de un instrumento para la evaluación inicial de enfermeira

“…Moreover, improvements in patient evaluation and concomitant documentation can influence the general quality of patient care (3,9) .…”

“…The attempt to achieve a nursing focus is a growing concern in the orientation of nursing assessment (4,9,11) .…”

“…This first phase is focused on the theoretical background of the construct for which an instrument is to be developed and involves an operational definition through the inclusion of representative items (21) . In our case, the researchers designed the instrument based on the theoretical constructs of Gordon's Functional Health Patterns, as well as comprehensive bibliography on initial nursing assessment (1,4,(7)(8)(9)(14)(15)17,19) . Thus, the following 12 categories are included: Physical assessment, Health perceptionmanagement, Nutritional-metabolic pattern, Elimination, Activity-exercise, Sleep-rest, Cognitive-perceptual pattern, Self-perception-self concept, Role-relationship, Sexuality-reproductive, Coping-stress tolerance and Value-belief.…”

“…This initial assessment phase, however, is not always performed systematically, either due to a lack of time (9)(10) and sufficiently useful instruments to guide patient assessment (4,9,(11)(12) or to nurses' lack of awareness on the application of the NP or health institutions' lack of involvement (2,13) .…”

“…Another problematic aspect in the assessment is the lack of a focus on the application of the NP (9,(14)(15) . In that sense, some authors have appointed that the availability of a well-designed assessment instrument presupposes help for nurses to gain critical thinking skills with a view to acknowledging what is relevant (1) , integrating the patient's psychosocial and physiological responses (16) .…”