Dokumentasjon av sykepleie i sykehjem: en vurdering av innhold og kvalitet på sykepleiedokumentasjonen og vurdering av reliabiliteten til instrumentet N-Catch
Engelsk titel: Nursing documentation in nursing homes: auditing of the content and quality of resident records and assessing the reliability of the measurement instrument N-Catch
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Författare:
Johnsen, Kjersti Frivoll
;
Ehrenberg, Anna
;
Fossum, Mariann
Email: kjersti.frivoll.johnsen@sshf.no
Språk: Nor
Antal referenser: 44
Dokumenttyp:
Artikel
UI-nummer: 14101153
Sammanfattning
Aim: The aim of the study was to describe the content and quality of the nursing documentation and to test the inter-rater and the test-retest
reliability of the N-Catch instrument on a sample of patient records from nursing home residents.
Background: Assessing nursing documentation with regular use of audit instruments may increase the quality of nursing documentation.
Methods: The study had a descriptive design. D-Catch was translated into Norwegian and named N-Catch. N-Catch was used to assess
200 resident records, collected from 4 nursing homes in 2009. An inter-rater reliability test and a test-retest were conducted.
Findings: The results showed that the assessed residents’ records contained personal data, admission notes, nursing care plans and progress
notes, but showed flaws in quality. The inter-rater reliability was rated between two independent raters and varied from 60 percent to 100
percent. The percentage agreement in the test-retest assessment of the items varied from 50 percent to 100 percent.
Conclusion: In conclusion, residents’ records contained personal data, admission notes, nursing care plans and progress notes, but showed
flaws in quality. The N-Catch instrument needs more testing to improve the reliability for assessing nursing documentation in patients’ records
from nursing homes.