Nursing care plans are fundamental to delivering quality patient care. To ensure these plans are effective and comprehensive, robust audit tools are essential. This article explores the development and validation of the Cat-ch-Ing instrument, an innovative audit tool designed to evaluate the quality and completeness of nursing documentation, ultimately enhancing patient care outcomes.
The impetus for the Cat-ch-Ing instrument arose from the need for a reliable method to assess nursing records against the VIPS model – a structured approach to documentation emphasizing wellbeing, integrity, prevention, and security. Researchers developed the Cat-ch-Ing tool with 17 specific questions targeting key aspects of nursing care documentation: assessment, diagnosis, planned interventions, and patient outcomes. This tool utilizes a rating scale, allowing for nuanced evaluation of both the quantity and quality of documented information within patient records.
To rigorously test the Cat-ch-Ing instrument, a study was conducted across three hospital wards, involving a thorough review of 60 patient records by three independent registered nurse auditors. The findings demonstrated exceptional inter-rater reliability, consistently exceeding 0.90 across all wards, indicating a high level of agreement among auditors using the tool. Furthermore, content validity, assessed by an expert panel, and criterion-related validity, measured against a pre-existing audit instrument, confirmed the Cat-ch-Ing tool’s accuracy and relevance in evaluating nursing documentation. The significant correlation (r = 0.68, p<0.01) with the established instrument underscored its validity.
The Cat-ch-Ing audit tool offers a valuable resource for healthcare professionals seeking to improve nursing care plan documentation. By providing a structured and reliable method for auditing records, it facilitates the identification of areas for improvement in care planning and delivery. The tool’s focus on the VIPS model further ensures a patient-centered approach to documentation and care. In conclusion, the Cat-ch-Ing instrument stands out as a valid and reliable audit tool, empowering nurses and healthcare institutions to enhance the quality and effectiveness of nursing care plans through comprehensive and consistent evaluation.
