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.
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