Quality indicators of the nursing process documentation in clinical practice

methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen’s kappa.

Results:

the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services.

Conclusions:

seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.

Descriptors:
Quality Indicators, Health Care; Documentation; Nursing Process; Nursing Records; Nursing Methodology Research

Content topic: Patient Identification (PI)		Input				Middle				Exit
Evaluation items		0	1	2	NA	0	1	2	NA	0	1	2	NA
PI1	The nursing documentation informs the patient's full name.
PI2	The nursing documentation informs the patient's date of birth or age.
PI3	The nursing documentation informs the patient's sex.
PI4	The nursing documentation informs the patient's unique registration number for the care system.

GUIDELINES FOR COMPLETING THE CliNDET
Content topic: Nursing Assessment (AE) on patient admission		Guidelines for evaluators
Analysis items		Guidelines for evaluators
AE1	The nursing assessment is documented at the appropriate time.	0 - there is no record of the NA; 1 - NA registration was made after the first 24 hours of entry into the care system, or it is not possible to identify when it was done; 2 - NA registration was made within the first 24 hours of entry into the care system.

Content Topics ^ e - entry; m - middle; s - exit .	Time^ e - entry; m - middle; s - exit .	Degrees of agreement between Landis and Koch⁽²⁰⁾					Total
Content Topics ^ e - entry; m - middle; s - exit .	Time^ e - entry; m - middle; s - exit .	Almost perfect (0.81-1.00)	Strong(0.61-0.80)	Moderate(0.41-0.60)	Median(0.21-0.40)	Insignificant(0.0-0.20)	Total
AE	e	15	2	-	-	-	17
PI	e	4	-	-	-	-	4
	m	1	3	-	-	-	4
	s	2	2	-	-	-	4
ND	e	7	3	2	-	-	12
	m	11	1	-	-	-	12
	s	11	1	-	-	-	12
NO	e	9	3	1	1	-	14
	m	7	7	-	-	-	14
	s	10	3	1	-	-	14
PN	e	13	-	-	-	-	13
	m	10	2	1	-	-	13
	s	10	2	1	-	-	13
GC	e	5	1	1	2	-	9
	m	5	-	3	1	-	9
	s	6	1	2	-	-	9
NN	e	2	4	2	1	-	9
	m	2	3	3	-	-	8
	s	10	6	2	-	-	18
Total	n	140	44	19	5	-	208
Total	%	67.3	21.2	9.1	2.4	-	100.0

Indicator	Institution A	Institution B
Nursing assessment - QICD-AE	82.40	73.74
Patient identification - QICD-PI	87.71	84.23
Nursing diagnoses - QICD-ND	62.33	74.97
Nursing orders - QICD-NO	75.31	80.10
Progress notes - QICD-PN	79.95	82.03
General characteristics of the registry - QICD-GC	93.48	72.18
Nursing notes - QICD-NN	76.99	76.09
QICD-Global	79.74	77.62

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Corresponding author: Oswalcir Almeida de Azevedo E-mail: oswalcir@terra.com.br