Audiing instrument for nurging care plans

Quality in Health Care 2000;9:6–13
Division of Nursing
Research at Karolinska
Hospital, Department
of Nursing, Karolinska
Institutet, Stockholm,
Sweden
C Björvell, PhD student,
registered nurse
I Thorell-Ekstrand, senior
lecturer
R Wredling, associate
professor
Correspondence to:
C Björvell
Email:
catrin.bjorvell@medks.ki.se
Accepted 13 December 1999
that have been planned for the patient. It is
used to ascertain the continuity of care among
caregivers. The nursing care plan is part of the
permanent patient record.
Since 1980, major health related organisations
and some western countries have begun
to develop standards, laws, and regulations
stating that the nursing process should be
included with nursing documentation. The
World Health Organisation,3 the International
Council of Nursing,4 the American Joint Commission
on Accreditation of Hospital Nursing
Service Standards,5 and the United Kingdom
Central Council6 all promoted the use of the
nursing process in nursing care. The Swedish
law on this subject was passed in 1986,7 and
was further clarified specifically for nursing by
the National Board of Health and Welfare in
1993 (box 1).
The development of written care plans has
been slow, however, and in Sweden nurses have
only recently started to produce a more structured
documentation of nursing. Nurses continue
to document care retrospectively rather
than document prospective care. Ehnfors
showed in 1993 that 90% of the audited patient
records lacked identified nursing problems,
goals, and nursing discharge notes.9 In two
thirds of the records, planned interventions
were not stated. In 1996, Nordström and Gardulf
stated that the nursing assessment was
insufficiently described in 60% of records10;
only 10% contained identified nursing problems
and goals; and less than 45% of the
records contained planned nursing interventions.
Even in 1999 Ehnfors and Ehrenberg
showed that only one of 120 patient records
contained a comprehensive description of a
patient problem, as prescribed by Swedish
law.11
Benefits of documentation
The main benefit of the documentation is
improvement of the structured communication
between healthcare professionals to ensure the
continuity of individually planned patient care.
Without an individualised care plan, nursing
care tends to become fragmentary and based
predominantly on institutional routine and
schedules. The care plan defines the focus of
nursing care not only to the nursing staff but
also to the patient and his relatives.12 By documenting
the agreement between patient and
nurse, an opportunity is provided for the
patient to participate in the decision making
about his own care.13 14 Moreover, the documentation
of expert nursing provides an
important source of knowledge to the novice
nurse and a potential instigation of the further
development of nursing theory.2 The care plan
yields criteria for reviewing and evaluating
care, financial reimbursement,12 and staffing.
Furthermore, a correlation between care plans
and positive patient outcomes, such as a
reduced stay in hospital, has been described.15
Documentation model
In 1992, a new documentation model was
developed and tested by Ehnfors, Thorell-
Ekstrand, and Ehrenberg.16 17 The model is
called VIPS, an acronym formed from the
Swedish words for wellbeing, integrity, prevention,
and security, which are seen as the major
goals of nursing care (fig 2). This model is
Assessment
Diagnosis and goal
Planned interventions
Implementation
Evaluation
Figure 1 The nursing
process model.
Nursing
history
• Reason for contact
• Health history
• Care in progress
• Hypersensitivity
• Social history
• Service
• Lifestyle
General
information
• Information
source
• Significant other
• Temporary
information
• Confidentiality
• Primary nurse
• Incidental/
progress notes
Nursing
status
Nursing
diagnoses
Nursing
goals
• Communication
• Knowledge/developement
• Breathing/circulation
• Nutrition
• Elimination
• Skin/tissues
• Wound
• Activity
• Sleep
• Pain/perceptions
• Sexuality/reproduction
• Psychosocial
• Emotions
• Relations
• Spiritual/cultural
• Wellbeing
• Composite assessment
• Medications
Nursing
interventions
Nursing
outcome
Planned - implemented
• Participation
• Information/education
• Support
• Environment
• General care
• Advanced care
• Training
• Observation/
monitoring
• Special care
• Wound care
• Drug handling
• Coordination
• Coordinated care
planning
• Discharge planning
Medical information
• Medical assessment
Discharge
notes
Figure 2 Flow diagram of the VIPS model for nursing documentation. Reproduced from Ehrenberg et at17with permission.
Regulations about nursing
documentation
“The patient record shall include a distinct
and clear nursing documentation. The
nursing documentation shall, from the
patient’s individual needs, describe the
planning, implementation and effects of the
nursing care. The documentation shall be
designed in such a way that it contributes to
secure patient safety and provides a basis for
continuous evaluation and revision of nursing
interventions. The nursing care shall be
summarised in a patient discharge note at
the time of discharge.”8 (Authors’ translation.)
Box 1 Regulations about nursing documentation as
stipulated by the Swedish National Board of Health and
Welfare
Development of an audit instrument for nursing care 7
designed to be used in the documentation of
the nursing process and therefore includes a
nursing care plan. The model also includes a
nursing discharge note. The purpose of the
model is to guide the nurse in the sequences of
assessment, problem identification, aim, planning
of interventions, implementation, and
evaluation of results and thereby to make nursing
documentation structured, adequate, and
easy to use in clinical care.
In the VIPS model, 13 keywords are used for
classifying the information collected by the
nurse about the patient’s situation and status
into categories, for example communication,
nutrition, and psychosocial status. Ten keywords
classify the nursing interventions into
categories such as information, support, and
environment. The use of keywords simplifies
information retrieval, although, to retrieve the
information asked for, a consensus about definitions
of categories must be reached.18 The
VIPS model provides such a lexicon, in which
each category, labelled by a keyword, has a
definition, a description, and prototypical
examples given in a manual. Keywords may be
seen as a first step towards a unified nursing
language for patient care.
The VIPS model has been received with
interest and appreciation by nurses in Sweden
and is now the most commonly taught and
used model for nursing documentation in hospitals
and primary health care.17
Auditing patient records
Audit has to be distinguished from traditional
review (box 2). The audit of patient records
may be done for several reasons. The most
common reason is because the audit is part of
an ongoing process of quality improvement. A
clinic may have agreed to document in a
certain way, possibly with a minimum data set
as a standard, or wants to evaluate specific criteria
for quality health care.19–21
Evidence exists that a continuously performed
audit of patient records, combined with
discussions about improvements, is one way to
improve the quality of the records and to
change certain behaviours of healthcare
professionals.22–24 Another benefit of auditing
documentation is that it makes comparisons
possible over time and among wards or hospitals,
provided that a reliable audit instrument is
used to put a numerical value on the written
content.25 26 Audit is also used to evaluate the
effects of quality management27 by identifying
the necessary professional strengths and the
weaknesses that need to be addressed and corrected.
Craig reports that nurses using her
audit tool acquired a better understanding of
what was expected of them for recording of
care and patient care itself, and also focused on
the areas that they specifically needed to
concentrate for improvement.28
It is important to differentiate between
auditing records for the sake of measuring the
quality of record keeping and auditing records
for the sake of measuring the quality of given
care. There is important criticism in the literature
about the auditing of patient records for
the purpose of checking patient care, the argument
being that patient records do not
necessarily reflect the reality of the given
care.29 30 This raises the question whether it is
possible to claim that audit measures the quality
of care. Whether better documentation can
also influence and improve patient care is
another question, not dealt with in this article.
Well written records, however, may be seen as a
step towards a process of quality assurance, as
a structured element in the nursing care. Donabedian
is careful to stress that good structure
only increases the likelihood of a good process
in the actual care given and that the correlation
between process and outcome has yet to be
shown.31
Two Swedish audit instruments have been
developed earlier, one by Ehnfors9 and the
other one by Gardulf and Nordström.10 Both
instruments are based on the nursing process
and evaluate the record in its quantitative
aspect; is there documentation for each function
or is there not? In addition, Ehnfors evaluates,
for each patient problem, the flow of
information in accordance with the nursing
process. Consequently, neither of the instruments
includes a qualitative evaluation of the
written content in the sense of the amount of
information, wording, pertinence, etc. Several
other audit instruments described in international
journals29 32–36 were also inadequate
with regard to the quality and quantity aspects
of auditing.
Improving nursing documentation is an
urgent issue. Poor documentation is an indication
that further investigation is needed to
judge whether or not the given care is less than
optimal. Audit instruments for nursing records
are therefore needed to identify poor assessment,
poor structure, and the lack of a plan for
the patient’s care. They are also needed for
evaluating the effects of interventions aimed to
improve the documentation.
The aims of this study were to develop an
audit tool to measure both the quantitative and
the qualitative aspects of nursing documentation,
based on the VIPS model, and to evaluate
the validity and reliability of that tool.
Methods
DEVELOPMENT OF THE INSTRUMENT
Before the instrument was constructed by two
of the authors (CB, IT-E), a set of criteria was
identified to determine what questions needed
to be answered about nursing documentation
“Differences between audit and traditional
review:
x Use of explicit criteria for measurement
rather than implicit judgments
x Numerical comparison of current practice
patterns against these criteria
x Formal identification of action required
to resolve any discrepancies disclosed
x Recording the process to retain information
and increase impact of audit on
future management.”19
Box 2 The difference between audit and review
8 Björvell, Thorell-Ekstrand, Wredling
in the patient record. These criteria were
derived from the following sources:
x The Swedish law that stipulates that nursing
documentation should include the steps of
the nursing process as described above, the
signing and dating of each entry, a minimum
degree of legibility, and a nursing discharge
note
x The VIPS model which includes the nursing
process, the use of specified keywords, the
correct classification of the keywords in
accordance with the user manual, and a
nursing discharge note
x Common hospital policies that prescribe
that each patient should have a named nurse
with the primary responsibility for the
patient’s nursing care and care plan documentation.
At this stage, 19 questions were formulated
to determine whether this information was
documented in the patient record. Each
question was constructed to reveal both the
quantity and the quality of the written content
on a rating scale. A manual was designed to
explain how to score each question.
The quality and quantity values were scored
on a rating scale from zero to three, zero indicating
“poor” and three indicating “very
good”. The quantity value is expected to measure
whether or not there is a written note and,
if so, how much is written. For example, for the
patient’s nursing status, a certain minimum
number of nursing areas, represented by
keywords in the VIPS model and relevant to
surgical care, should be described for a patient
in a surgical ward. The quality value is used to
measure to what degree the written notes are
clear and concise, without superfluous text,
and include all relevant nursing information
with a correct use of language. If all notes fulfil
these criteria, a full score of three is given; if
more than 50% of the notes, but not all of
them, fulfil the criteria, a score of two is given;
if less than 50% fulfil the criteria, though some
notes still fulfil the criteria, a score of one is
given, etc. Furthermore, the instrument is
expected to measure the extent to which it is
possible to follow a patient problem through
the nursing process. That is, whether the problem
is properly assessed and described in a
diagnosis, with the expected outcome, planned
and implemented interventions, and an evaluation.
The instrument was named Cat-ch-Ing.
To test usability for understanding questions
and phrasing of the instrument, five patient
records collected from one hospital ward were
independently reviewed by three nurses using
the new instrument. The instrument was
revised after each of the three audits. The revisions
concerned the clarification of definitions
in the manual and the deletion or rephrasing of
questions. Two questions were omitted, one
about the evaluation of nursing care, which was
already covered by other questions, and the
other about the use of keywords other than
those stipulated by the VIPS model. One question
about the discharge note was rephrased.
TESTING OF RELIABILITY AND VALIDITY
Inter-rater reliability was tested by comparing
different reviewers’ total Cat-ch-Ing scores
given to the same record. Twenty patient
records from each of three hospital wards at a
university hospital in Stockholm, Sweden were
used for this part of the development. The
records were selected from the registers of the
wards and were coded to protect patient identity.
The specialty wards were surgery, neurology,
and rehabilitation. The criteria for the collection
of the records were that they should
concern the first 20 patients from each ward
who were admitted for five days or more during
a specific time period. The collected records
were audited three times, each time by a different
reviewer. The auditors were nurses knowledgeable
and experienced in nursing documentation
and in the use of the VIPS model.
Before the audit, a calibrating process was
undertaken, which means that the use of the
instrument was taught and discussed with the
reviewers.
The inter-rater reliability was statistically
investigated by calculating the inter-rater reliability
coefficient37 between raters’ total scores
of each record. Additionally, score differences
between reviewers, on each question in the
same patient record, were compared and
calculated as percentages of agreement.
The content-validity ratio was calculated as a
means of quantifying the degree of consensus
in a panel of 10 experts, who made judgments
about the instrument’s content validity. Each
expert was asked to judge whether or not the
10 questions in the instrument, meant to
measure the nursing process, were indeed
essential in measuring the parts of the nursing
process documented in a patient record. The
method, developed by Lawshe,38 is described
by the formula:
where CVR is the content-validity ratio, ne is
the number of panellists indicating “essential”
about a specific question and N is the total
number of panellists.
The criterion-related validity was estimated
by the degree of correlation between the score
of the Cat-ch-Ing instrument and the score of
the audit instrument developed by Ehnfors9
and used in previous research. The Ehnfors
instrument was constructed to measure
whether each part of the nursing process (and
thereby also the VIPS model) was documented
for each nursing problem identified in the
patient record. The nursing process was the
chosen criterion in both the Ehnfors and the
Cat-ch-Ing instrument. The Ehnfors instrument
has a score from zero to five, giving one
point for each documented part of the nursing
process: assessment, goal and diagnosis,
planned intervention, implemented intervention,
and a discharge note, concerning each
specified nursing problem. The Ehnfors instrument
scores mainly the quantity; the quality
aspect is only present for evaluating the flow of
Development of an audit instrument for nursing care 9
information in the nursing process for each
patient problem.
A mean Ehnfors score of all identified nursing
problems in a record was calculated and
compared with the total score given by the
Cat-ch-Ing instrument for the same record.
The results were then tested by the use of
Pearson’s correlation coefficient.
The research protocol was approved by the
regional ethical committee of the Karolinska
Institutet.
Results
The final version of the Cat-ch-Ing instrument
(appendix), which was completed in December
1996, consists of 17 questions: 10 reflecting the
presence of each step of the nursing process;
four about dating, signatures, and legibility;
one about keywords; and one asking about the
existence of the individual patient’s named
nurse.
SCORING
The total score ranges from zero to 80 points.
Sixty eight per cent of the total score may be
achieved by questions that are posed to
measure the content of the nursing process;
15% relate to questions that judge legibility,
signing, and dating; 7% correspond to keywords;
5% to the nursing discharge note; and
5% to the identification of a primary nurse.
Nine of the questions may be rated for quantity
and quality. Five questions can be rated
only for quantity, for example “are all entries
signed?”, and one question about legibility is
rated only for quality. The two remaining
questions have “yes” or “no” answers (fig 3).
The inter-rater reliability coefficients were
calculated to be 0.98, 0.98, and 0.92 for each
group of patient records from the three wards.
The content validity ratio between the expert
panellists (table 1) ranged between 0.20 and
1.0. Of the 12 items measuring the nursing
process in the instrument, all but three were
judged to be essential by the expert panellists.
The criterion related validity for the Cat-ch-
Ing instrument was illustrated by the significant
correlation (r = 0.68, p = <0.0001, 95%
CI 0.57 to 0.76) between the scores of the
Ehnfors and the Cat-ch-Ing instruments (fig
4).
On examining the score differences between
the three reviewers on each question (n=4680
comparisons) we found no differences in scores
in 64% of the comparisons. Thirty two per cent
of the comparisons differed by one point and
4% differed by two or three points. The largest
score differences (two or three points) occurred
on the items of qualitative judgment of nursing
assessment and nursing interventions. Larger
records (for example, 56 pages of text) had a
greater discrepancy among raters scoring the
same record than less extensive records.
Discussion
This study has resulted in a new instrument for
auditing nursing documentation of the patient
record. The instrument has proved to be valid
for measuring information pertinent to the
nursing process, and to possess a high degree of
reliability when used by different auditors.
In the few records in which an increased discrepancy
among auditors was noted, the
patient records proved to be comprehensive.
The reasons for the discrepancy may be that it
Is there a nursing history?
Is there a patient status:
On arrival?
Updated?
At discharge?
Is there a nursing care plan:
Nursing diagnosis?
Expected outcome?
Interventions:
Planned?
Implemented?
Is the underlying information
for nursing diagnosis described
in the nursing status?
Is the nursing outcome described?
Explanation of the interpretation of given scores
The box describes the questions in the instrument that reflect the nursing
process, with the shaded area encompassing the parts adherent to the
nursing care plan. The scores for quantity and quality about the care plan
show that, for this patient, there were few, but still some, planned nursing
interventions documented (quantity = 1). Those that were documented
had excellent quality (quality = 3). However, there is no description at all
of analysis of the patient problem (nursing diagnosis) or the aim of the
care that supposedly led the nurse to her choice of intervention.
Quantity: 3
Quantity: 2
Quantity: 2
Quantity: 3
Quantity: 0
Quantity: 0
Quantity: 1
Quantity: 2
Quantity: 0
Quantity: 3
Quality: 1
Quality: 2
Quality: 1
Quality: 2
Quality: 0
Quality: 0
Quality: 3
Quality: 2
Figure 3 Example of scoring in an audit of one patient record.
Table 1 Content validity ratio between expert panellists judging items of the instrument as
essential or not in measuring the nursing process in the patient record
Item
Judged as “essential”
by experts (n=10) Ratio
Is there a nursing history? 9/10 0.80
Is there a nursing status:
On arrival? 10/10 1.0
Updated? 9/10 0.80
On discharge? 8/10 0.60
Is there a nursing care plan:
Nursing diagnosis? 10/10 1.0
Expected outcome? 7/10 0.40
Interventions:
Planned? 9/10 0.80
Implemented? 9/10 0.80
Is the underlying information for the nursing diagnosis described
in the nursing status?
6/10 0.20
Is the nursing outcome described? 9/10 0.80
5
4.5
3
4
2.5
2
1.5
1
0.5
0
_0.5
3.5
Ehnfors score
10 20 30 40 50 60 70 80
Cat-ch-Ing score
Figure 4 Correlation between the Ehnfors audit instrument
and the Cat-ch-Ing audit instrument for nursing
documentation, r = 0.68, p <0.0001, 95% CI 0.57 to
0.76.
10 Björvell, Thorell-Ekstrand, Wredling
is harder to keep track of pertinent information
in a large mass of nurses’ notes, or simply that
the auditor loses concentration after reading
the same record over a long period.
The Cat-ch-Ing instrument has been thoroughly
investigated for validity and reliability.
Two types of validity have been confirmed, and
using three reviewers in the reliability testing
strengthens the results. The Cat-ch-Ing instrument
showed a strong validity for measuring
whether the nursing process existed in the
patient record, which is one of the main
strengths of the instrument. It clearly gives a
measure not only of the amount of written text
but also, most importantly, of the quality of the
information that has been documented. Furthermore,
the Cat-ch-Ing is only a one page
instrument with a two page manual, whereas
other instruments usually have more extensive
instructions, and this may be a facilitating
factor.
Various limitations to the study should be
highlighted, however. Firstly, the auditors were
selected because of their knowledge and
experience in documentation, as well as in
nursing. This was thought to be a necessary
prerequisite when developing a new instrument.
We have not tested the instrument
among nurses in general. Secondly, the study
dealt with records from the wards of a major
university hospital that provides somatic acute
care and short term rehabilitation. The testing
we did could be considered valid for this type of
record only. Thirdly, the weighting of the scores
between the various questions may have to be
adjusted; as much as 32% of the score can be
achieved by dating and signing correctly, by
recording the named nurse, by using a
typewriter, and by using the keywords of the
VIPS model correctly. None of this indicates
the nursing process.
The development and testing of the Nordström
and Gardulf audit instrument for
nursing documentation has not been scientifically
described in the literature. The Phaneuf
Nursing Audit tool has been described in
numerous papers. Neither of these produces a
clear result of validation and reliability testing.
Also, the Phaneuf instrument claims to measure
the quality of care by auditing the patient
record and has received criticism for this.29 32 36
The Ehnfors instrument,9 used as a comparison
in this study, has an obvious, high, face
validity and inter-rater reliability when tested
by Kohen’s ê (ê = 0.93).
Group level comparisons with inter-rater
reliability coefficients in the vicinity of 0.70
show sufficient reliability.39 Thereby the reliability
of the Cat-ch-Ing instrument, with a
coefficient of 0.98, proved to be very satisfactory.
It is a known problem that auditing
patient records involves subjective judgments.39
Less inference is required of the auditor when
reviewing the documentation of demographic
information compared with that required when
assessing the adequacy of documentation
related to the patient specific needs and specific
nursing skills, such as educational strategies
and information giving.40
According to Lawshe,38 the minimum value
of the content validity ratio to ensure that
agreement is unlikely to be due to chance, with
10 panellists, is 0.62 per identified item. This
indicates that the Cat-ch-Ing instrument to a
large degree measures the documented nursing
process in the patient record, as intended.
Seven out of 10 items in the instrument
received satisfactory values. The three items
that received a lower value will be considered
for exclusion. The reasons for the lower value
for the questions, “is the underlying information
for the nursing diagnosis described in
the nursing status?” and “is there a new nursing
status at the time of discharge?”, may be
because the questions were thought to be
already covered by other questions in the
instrument. Why a lower value was given to the
question, “is the expected outcome (goal)
documented in the care plan?” is more difficult
to explain. One reason may be that the expert
panellists all work with the nursing process
model in a theoretical setting where the patient
outcome is not an explicit part of the model,
whereas in the practical setting it is an explicit
part of the model.
The fact that yet another nursing audit
instrument has been developed and tested
implies to nurses that the auditing of nursing
performance is an important subject, possibly
making more nurses familiar with auditing and
quality improvement. One approach to increasing
the awareness and knowledge of the auditing
of nursing documentation and care planning
is to encourage the use of a peer review
system. By using an instrument like the
Cat-ch-Ing, peer review of patient records may
be a means not only of improving patient
records but also of instigating a discussion and
thereby possibly reaching a consensus on best
nursing care in specific situations, which may
improve direct care.
The criterion based audit is a concept used
in medicine8 which may be applicable to nursing
also. In this study, the nursing process was
used as the evaluated criterion because this is
what Swedish law prescribes, and may be seen
as the short term goal—to improve nursing
documentation and record keeping. However,
the Cat-ch-Ing instrument is constructed so
that it could be modified to measure specific
criteria of nursing care quality, as documented
in the patient record. Modification would then
be described in the user manual, for example
what interventions are expected in the nursing
care plan for a patient with a specific problem
to get a full score, or what specific information
will be expected under the keyword of
nutrition for a patient with newly discovered
diabetes in order to get a full score. This may
be seen as a long term goal of auditing within
nursing care.
Conclusion
It can be concluded that the Cat-ch-Ing
instrument proved to be a valid and reliable
audit instrument for nursing documentation
in patient records when the VIPS model was
used as the basis of the documentation. Nursing,
as a growing scientific discipline, is
Development of an audit instrument for nursing care 11
constantly adding new knowledge to clinical
care and thereby increasing the need to be able
to detect whether patient care was documented
in accordance with scientific findings.
The next step, once record keeping is
improved, will be to evaluate the effect that it
has on patient care.
We are grateful to the Stockholm County Council, whose generous
grant made this study possible. We also thank Anders
Sjöberg for statistical advice.
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Record #:
Date:
Read the User Manual carefully
* = see the User Manual.
Scores within brackets.
Is there a primary nurse indicated?
Is there a nursing history?
Is there a nursing status:
On arrival?
Updated?*
At discharge?
Is there a nursing care plan:
Nursing diagnosis?*
Expected outcome?*
Interventions:
Planned?
Implemented?
Is the underlying information for the
nursing disgnosis described in nursing status?
Is nursing outcome described?*
Are the VIPS keywords used?*
(regarding history, status, interventions)
Is there a nursing discharge note?
Are all entries dated (year, month, day)?
Are all entries signed?
Is there a clarification of signature?
Is the record legible?*
no
only by surname
by surname and christian name
(0)
(2)
(4)
Ward:
Reviewer:
Hospital:
Quantity*
Complete = (3)
Partly = (2)
Occasional = (1)
None = (0)
Quality*
Very good = (3)
Good = (2)
Less good = (1)
Poor = (0)
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity: Quality:
Quantity:
Quantity:
Quantity: Quality:
Quantity: Quality:
Yes (4) No (0)
Quantity:
Quantity:
Quantity:
Quality:
Total score: (max 80)
Appendix
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