Documentation Audit Tool Print

Original Citation – Cooper M, Kinn S, Ibbotson T, Lindsay G, Swann I. Emergency nurse practitioner's documentation: development of an audit tool. Emerg Nurse. 2000 Sep;8(5):34-9. View in PubMed

Contact Information
Dr Mark Cooper
Lecturer Practitioner
Accident and Emergency
Jubilee Building
Glasgow Royal Infirmary
Alexandra Parade
Tel: 0141-211-0558
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Price & Availability – Contact author for permission to use.  Click here to view instrument.

Brief Description of Instrument – Measures the quality of clinical notes of patients with minor injuries seen in the ED. Measures the number of essential criteria of notes of minor injury.

Scale Format – Checklist.

Administration Technique – Researcher reviews patient records and fills out sections that are applicable to case.

Scoring and Interpretation – To calculate final score, add the total number of criteria correctly documented in the notes [Total score]. Add up the maximum possible score for that particular set of notes (i.e. the maximum score in each of the groups of criteria used in each section) [Maximum possible score]. Divide the total score by the maximum possible score and multiply by 30. This will give you your final score for that set of notes. Score is out of 30.

Factors and Norms – Comprised of 1) core criteria, 2) investigations, medication and discharge, 3) wounds and burns, 4) limb injuries, 5) minor head injuries.

Inter-rater Reliability – Three people reviewed and rated 20 notes. Pearson correlation 0.68.

Content & Face Validity – Developed using expert panel and consensus methodology, modified nominal group technique. This technique makes use of group problem solving by drawing on: brainstorming, voting, the Delphi process and committee work.

Published APN Studies using instrumentCooper MA, Lindsay GM, Kinn S, Swann IJ. Evaluating Emergency Nurse Practitioner services: a randomized controlled trial. J Adv Nurs. 2002 Dec;40(6):721-30.