Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records
Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records
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DOI：
10.1111/scs.12049
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发表时间：
2014-06-01
影响因子：
1.9
通讯作者：
Andersson, Agneta
中科院分区：
文献类型：
--
作者：
Lovestam, Elin;Orrevall, Ylva;Andersson, Agneta
医疗记录中充分的文件对高质量的卫生保健很重要。文献质量在护理领域得到了广泛的研究，但在饮食护理领域研究较少。本研究的目的是翻译、阐述和评估一种基于四步营养护理过程模型的审计工具，用于记录医疗记录中的营养护理。审计工具包括14个项目，重点关注饮食保健的基本部分以及文件的清晰度和结构。每项评分为0-1或0-2分，总分最高为26分。为了便于解释和提高仪器的可靠性，增加了一份详细的手册。该工具是基于9年前在美国发起的类似工具，在本研究中被翻译成瑞典语并进一步阐述。翻译和进一步阐述的文书被命名为Diet-NCP-Audit。首先，由五位经验丰富的营养师对Diet-NCP-Audit量表的内容效度进行检验。他们对所包括的项目的相关性和清晰度进行了评级。在第一次评级之后，进行了一些小的改进。第二次评定后，内容效度指数为1.0，清晰度指数为0.98。其次，为了检验可靠性，4位营养师使用审计仪器独立审核了系统收集的20份饮食笔记。评审前，进行了校准过程。对评价进行比较，结果与Krippendorff的alpha=0.65-0.67一致。将审计结果分为三个层次：较低、中等或较高的范围，Krippendorff的alpha值为0.74被认为是高可靠性。此外，由一名营养学家进行的间隔9周的内部可靠性测试显示了强烈的一致性。综上所述，所评估的审计工具具有较高的内容效度和中至高的信度，可用于饮食保健文件的审计。
Adequate documentation in medical records is important for high-quality health care. Documentation quality is widely studied within nursing, but studies are lacking within dietetic care. The aim of this study was to translate, elaborate and evaluate an audit instrument, based on the four-step Nutrition Care Process model, for documentation of dietetic care in medical records. The audit instrument includes 14 items focused on essential parts of dietetic care and the documentation's clarity and structure. Each item is to be rated 0-1 or 0-2 points, with a maximum total instrument score of 26. A detailed manual was added to facilitate the interpretation and increase the reliability of the instrument. The instrument is based on a similar tool initiated 9years ago in the United States, which in this study was translated to Swedish and further elaborated. The translated and further elaborated instrument was named Diet-NCP-Audit. Firstly, the content validity of the Diet-NCP-Audit instrument was tested by five experienced dietitians. They rated the relevance and clarity of the included items. After a first rating, minor improvements were made. After the second rating, the Content Validity Indexes were 1.0, and the Clarity Index was 0.98. Secondly, to test the reliability, four dietitians reviewed 20 systematically collected dietetic notes independently using the audit instrument. Before the review, a calibration process was performed. A comparison of the reviews was performed, which resulted in a moderate inter-rater agreement with Krippendorff's alpha=0.65-0.67. Grouping the audit results in three levels: lower, medium or higher range, a Krippendorff's alpha of 0.74 was considered high reliability. Also, an intra-rater reliability test-retest with a 9weeks interval, performed by one dietitian, showed strong agreement. To conclude, the evaluated audit instrument had high content validity and moderate to high reliability and can be used in auditing documentation of dietetic care.