Table 3 The N-Catch scores of accuracy of documentation in the psychiatric nursing record
From: Assessment of quality in psychiatric nursing documentation – a clinical audit
Element of the N-Catch | Scale | Score, mean (95% CI) | N | Score 3 n (%) | Score 2 n (%) | Score 1 n (%) | Score 0 n (%) | |
|---|---|---|---|---|---|---|---|---|
Quantity | Quality | |||||||
Record structure | 0 – 3 | 2.7 (2.54 – 2.89) | 21 | 15 (71) | 6 (29) | 0 | 0 | |
The patient’s personal details | 0 – 2 | 2.0 | 21 | 0 | 21(100) | 0 | 0 | |
Admission note | 0 – 3 | 0.9 (0.45 – 1.35) | 201 | 2 (10) | 4 (20) | 4 (20) | 10 (50) | |
Admission note | 0 - 3 | 1.3 (0.86 – 1.64) | 201 | 1 (5) | 8 (40) | 6 (30) | 5(25) | |
Nursing care plan | 0 – 3 | 1.7 (0.78 – 2.14) | 21 | 6 (28,5) | 6 (28,5) | 5 (24) | 4 (19) | |
Nursing diagnoses | 0 - 3 | 1.5 (1.01 – 1.95) | 21 | 4 (19) | 3 (38) | 3 (14) | 6 (29) | |
Nursing outcomes | 0 - 3 | 0.8 (0.29 – 1.23) | 21 | 3 (14) | 2 (10) | 3 (14) | 13 (62) | |
Nursing interventions | 0 - 3 | 1.2 (0.86 – 1.52) | 21 | 5 (14) | 6 (28) | 10 (48) | 4 (19) | |
Progress report | 0 – 3 | 0.2 (−0.02 – 0.42) | 21 | 0 | 1 (5) | 2 (9) | 18 (86) | |
Progress report | 0 - 3 | 1.4 (1.11 – 1.66) | 21 | 0 | 10 (48) | 9 (43) | 2 (9) | |
Discharge note | 0 - 3 | 1.7 (1.24 – 2.10) | 182 | 3 (16,7) | 8 (50) | 3 (16,5) | 3(16,7) | |