Development of a measurement instrument for nursing documentation in the patient record.

OBJECTIVES

To develop, validate and test the reliability of a measurement instrument that measures the extent to which records describe essential aspects of nursing care such as the admission report, nursing diagnoses, interventions, and progress and outcome evaluations.

METHOD

A measurement instrument was developed based on the Cat-ch-Ing instrument and the Scale for Degrees of Accuracy in Nursing Diagnoses. A record screening was conducted in 7 hospitals in the Netherlands. Content validity was tested by using two Delphi panels. Each of the 250 records was assessed by two reviewers independently. The reliability of the instrument was tested by calculating Cohen's weighted Kappa inter-rater reliability coefficient of 250 records and 12 reviewers. Internal consistency was calculated by using Cronbach's alpha.

RESULTS

The new measurement instrument, named D-Catch, consists of six items. Quantity and quality variables were used to judge the accuracy of the nursing documentation. Internal consistency: Cronbach's Alpha 0.722. The inter-rater reliability coefficients were between 0.397-1.000.

CONCLUSIONS AND IMPLICATIONS

The D-Catch instrument was estimated to be a valid and reliable measurement instrument for nursing records in hospitals in the Netherlands. An adverse effect on the inter-rater reliability may have been that, specifically in long stay situations, documentation forms with diagnoses, interventions and outcomes were often unstructured and found to be repetitious.