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

Abstract

This study validates and tests the reliability of an audit instrument constructed to evaluate the content of nursing discharge notes. Instrument validation and reliability testing. Factor analysis identifying structure through data summarization of the instrument, association between scores in test-retest, and interrater reliability between auditors. Three factors emerged in the factor analysis: 'General information', 'Planning', and 'Assessment', accounting for 76% of the variance regarding the quantitative aspect and 79% of the variance regarding the qualitative aspect, confirming the distinctiveness. Reliability: The Spearman rank-order correlation coefficient calculated per item in the test-retest ranged from 0.72 to 1.0 (p=0.01). The correlation coefficient for the total score was 0.98 (p=0.01). There were no differences in item scores between the test and retest in 93% of the comparisons (n=486). Between the two auditors, the Spearman rank-order correlation coefficient in each item ranged from 0.83 to 1.00 (p=0.01) and weighted kappa values from 0.70 to 1.00 with the exception of one item in both calculations. The correlation coefficient for the auditors' total score was 0.99 (p=0.01). The Student's paired t-test comparing the two auditors' mean values in five different parts of the instrument showed no significant differences in score. The Cat-ch-Ing EPI instrument shows a high reliability and validity as an audit instrument to evaluate the content of nursing discharge notes.