Nursing clinical registers quality: the generation of an assessment instrument

Abstract

Introduction: Nursing clinical registers represent written evidence of care given to patients, and a means of communication and coordination between health professionals; therefore, their correct constitution allows continuity in patient care security. 

Objective: Build and validate an instrument to assess nursing clinical registers quality. 

Methodology:we started searching in diverse databases including PubMed, MEDLINE, Elsevier, Cochraner, and also consulted the Health General Law, the Mexican Official Standard NOM-168-SSA-1998, the Ethical Code for Mexican Nurses, the standards of the General Health Council of the Medical Attention Sites Certification, and the Public Sector Third Level Attention Medical Units Sub-Direction. The instrument was named CARCE and it estimates three dimensions of care: structure, continuity, and patient security. 

Results: we calculated the Kuder- Richardson coefficient (.86) and the Mann-Whinney and Kruskal-Wallis coefficients to test variable-discrimination power and obtained statistically significant differences (p= .0001). 

Discussion:similar to the VIPS model, which tests well-being, integrity, prevention, and security seen as the principal nursing care objectives from the perspective of Bjorvell et al, the CARCE instrument was found to be useful to help integrate patient security and health care continuity. 

Conclusion:the instrument gathers the essential elements of validity and confidence as well asvariable-discrimination power, and because of this, we propose it as an option toassess nursing clinical objectives both in public and in private institutions.