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

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 coefficient. 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 coefficient.

Results: The new audit instrument, named Cat-ch-Ing, consists of 17 questions designed to judge the nursing documentation. Both quantity and quality variables are judged on a rating scale from zero to three, with a maximum score of 80. The inter-rater reliability coefficients were 0.98, 0.98, and 0.92, respectively for each group of 20 records, the content validity ratio ranged between 0.20 and 1.0 and the criterion related validity showed a significant correlation of r = 0.68 (p < 0.0001, 95% CI 0.57 to 0.76) between the 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 basis of the documentation.