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

Objectives-To develop, validate, and test the reliability of an audit instr ument that measures the ex-tent to which patient records describe important aspects of nursing care. Material-Twenty records from each of three hospital wards were collected an d audited. The auditors were registered nurses with a knowledge of nursing documentation in accordance with the VIPS model-a model designed to structu re 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 p atient for nursing assessment, nursing diagnosis, planned interventions, an d outcome. Each of the 60 records was reviewed by the three auditors indepe ndently 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 r elated validity was estimated by the correlation between the score of the C at-ch-Ing instrument and the score of an earlier developed and used audit i nstrument. The results were then tested by using Pearson's correlation coef ficient. Results-The new audit instrument, named Cat-ch-Ing, consists of 17 question s designed to judge the nursing documentation. Both quantity and quality va riables are judged on a rating scale from zero to three, with a maximum sco re of 80. The inter-rater reliability coefficients were 0.98, 0.98, and 0.9 2, respectively for each group of 20 records, the content validity ratio ra nged between 0.20 and 1.0 and the criterion related validity showed a signi ficant correlation of r = 0.68 (p < 0.0001, 95% CI 0.57 to 0.76) between th e 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 bas is of the documentation.