Table 4 Adherence to recommended documentation practice in 38 patient records at a residential care centre

Nursing assessment on admission ^b

0.8 (0.3–1.2)

1.9 (1.5–2.2)

1.1 (0.6–1.7)

< 0.001

Nursing diagnoses

1.1 (0.9–1.3)

1.7 (1.5–1.8)

0.5 (0.3–0.7)

< 0.001

Aims for nursing care

0.4 (0.3–0.6)

1.0 (0.8–1.1)

0.5 (0.3–0.8)

< 0.001

Nursing interventions

0.9 (0.8–1.1)

1.4 (1.3–1.6)

0.4 (0.2–0.6)

< 0.001

Evaluation/progress reports

0.8 (0.6–1.0)

0.9 (0.8–1.0)

0.0 (-0.2–0.1)

0.6

^aMD Mean difference

^b “Nursing assessment on admission“ was missing in 22 records at audit and 3 records at re-audit. The N-Catch II did not provide a scoring option for missing values for these cases