Testing of an audit instrument for the nursing discharge note in the patient record.

Scand J Caring Sci; 2004; 18; 318–324Testing of an audit instrument for the nursingdischarge note in the patient recordObjectives. This study validates and tests the reliability of anaudit instrument constructed to evaluate the content ofnursing discharge notes.Design. Instrument validation and reliability testing.Main outcome measures. Factor analysis identifying structurethrough data summarization of the instrument, associationbetween scores in test–retest, and interrater reliabilitybetween auditors.Results. Validity: Threefactorsemergedinthefactoranalysis:‘General information’, ‘Planning’, and ‘Assessment’,accounting for 76% of the variance regarding the quanti-tative aspect and 79% of the variance regarding the qual-itativeaspect,confirmingthedistinctiveness.Reliability:TheSpearman rank-order correlation coefficient calculated peritem in the test–retest ranged from 0.72 to 1.0 (p ¼ 0.01).The correlation coefficient for the total score was 0.98 (p ¼0.01). There were no differences in item scores between thetest and retest in 93% of the comparisons (n ¼ 486).Between the two auditors, the Spearman rank-ordercorrelationcoefficientineachitemrangedfrom0.83to1.00(p ¼ 0.01) and weighted kappa values from 0.70 to 1.00with the exception of one item in both calculations. Thecorrelation coefficient for the auditors’ total score was 0.99(p ¼ 0.01). The Student’s paired t-test comparing the twoauditors’ mean values in five different parts of the instru-ment showed no significant differences in score.Conclusion. The Cat-ch-Ing EPI instrument shows a highreliability and validity as an audit instrument to evaluatethe content of nursing discharge notes.Keywords: audit instrument, nursing documentation,nursing discharge notes, quality assurance.Submitted 6 April 2004, Accepted 11 June 2004