auditing nursing content in patient records

OR IG INAL ART ICLE

Auditing nursing content in patient records

Anna Ehrenberg1,2RN, Margareta Ehnfors1,3,4

RNT, DMSc (Nursing)

and BjoÈ rn Smedby1MD, PhD

1Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden, 2School of Health and Caring Sciences, University

College of Dalarna, Falun, Sweden, 3Department of Caring Sciences, OÈ rebro University, OÈ rebro, Sweden, and 4Swedish Society of Nursing,

Stockholm, Sweden

Scand J Caring Sci; 2001; 15; 133±141

Auditing nursing content in patient records

The objective of this paper is twofold: (a) to explore

different approaches in reviewing records based on a lit-

erature review of studies of audits of patient records and

(b) to apply these approaches on a sample of records to

illuminate consequences of their application.

The method used was a literature review of papers on

recording of nursing care (n � 56). Based on our ®ndings,

an audit of a strati®ed sample of records (n � 298) from

Swedish community health care and nursing homes was

performed, applying the different approaches for auditing

previously described in the literature.

The review showed that audits of patient records were

performed using four different approaches with varying

aims. The focus of the four approaches can be described as

formal structure, process comprehensiveness, knowledge-

based and concordance with actual care. The results of this

study suggest that audits of patient records should not

be solely limited to encompass the formal structure of

recording. To avoid a super®cial picture or a false sense

of high quality and to obtain a more complete and reliable

portrait of the quality of recording, we suggest the process

comprehensiveness approach in combination with a

critical review of the knowledge base for the assessment,

diagnosis and interventions of patient records.

Keywords: medical records, audits, nursing.

Submitted 27 December 1999, Accepted 20 June 2000

Introduction

There is a strong potential of the patient record to be a

highly useful instrument in planning and implementing

care for the individual patient. A systematically written

and process focused record has been described as an

important basis for quality patient care (1, 2). The demand

is growing on the patient record to serve as a data-source

for purposes additional to every day patient care. Assess-

ment of the quality of care has become more important

as a means to enhance continuous improvements and

evidence-based practice. The patient record is one

important source of information as the data in the records

are available even after the care episode has terminated. In

order that the patient record serves as an essential source

of information, however, the record must accurately

re¯ect the actual care that was given (3). Relative to other

approaches it may be a cost-effective means of collecting

data provided that records are computerized or at least

structured in an accessible way (4). The potential use of

patient records has been described by the Swedish National

Board of Health and Welfare to be a source of information

for the patient, an instrument for quality assurance and

control, for legal use and for research (5). Data from

patient records are frequently being used in research. In

examining eight issues of the scienti®c journal Nursing

Research, Von Koss Krowchuk et al. (6) found that 25% of

the studies used some kind of health care record as a data

source.

In addition to more readily available information in daily

patient care, there will probably be an increasing interest

in utilizing data from patient records because of greater

availability and accessibility through computerization.

Electronic patient records will require a more structured

and uniform format of organization, which will increase

the possibilities of using the records for various purposes

(3). With a uniform and controlled vocabulary, the com-

puterization will provide access to large and representative

samples of data for patient groups or clinical areas. This will

enable growth of clinical knowledge based on aggregated

data about prevalent patient problems, care interventions

and outcomes of care (7). In this regard, it is important to

consider the usefulness of the patient record as a source of

information, as well as to develop methods for valid and

Correspondence to:

Anna Ehrenberg, Dalarna University, SE-791 88 Falun, Sweden.

E-mail: [email protected]

ã 2001 Nordic College of Caring Sciences, Scand J Caring Sci 133

reliable data collection and for reviewing different aspects

of patient care through records (4). Still, there are few

studies devoted to this question (3).

Instruments for record audit in nursing

Several internationally recognized instruments for asses-

sing the quality of nursing care have focused on record

audit. The Phaneuf audit was developed already in the

1950s and centred exclusively on retrospective reviews of

records (8). The instrument was based on the assumption

that good quality recording re¯ects good quality care.

Other early instruments that are still in use for quality

assessment in nursing and that partly use concurrent

record audits are the Quality Patient Care Scale (QualP-

ACs) by Wandelt & Ager (9), the Rush Medicus Process

Instrument (10) and the Monitor, an instrument derived

from the Rush Medicus Process Instrument (11). All these

instruments concentrate on the occurrence of speci®c

record content pertaining to the phases of the nursing

process. The audit comprises general criteria for good

nursing care. Concerning the Rush Medicus Process

Instrument, extensive testing of validity, though limited to

the performance of the instrument itself, has been made.

Answers to the crucial question ± to which extent do the

instruments measure the actual quality of care or other

important aspects ± have not yet emerged (12).

In Sweden, the record audit for assessing the quality of

care has been used only to a limited extent (13±15). Audit

instruments using records have mainly been developed

with the aim of assessing the quality of the record ± not the

actual quality of nursing care (16, 17). In some of these

studies assumptions have been made implicating a rela-

tionship between recording and actual care, where it is

presumed that good recording re¯ects good care planning

and nursing care. It is not as evident, however, that de®-

ciencies in recording correlate with poor nursing care (18).

During recent years audits of patient records with the

purpose of assessing quality patient care have been

developed towards assessment of speci®c quality indicators

related to the process and outcome of care (19).

Records and the reality of the patient

The documentation in patient records is assumed to be

accurate, reliable and legally sound. Nevertheless, little is

known about the ability of the records to re¯ect accurately

the patient's problems, care interventions and outcomes of

care. Some studies have revealed considerable shortcom-

ings regarding accordance between the record and the

reality in nursing care (20±22). In numerous other studies

that used recorded data, it is unknown if the lack of

information in the records re¯ects de®ciencies in nursing

practice or in nursing recording (e.g. merely showing that

what is written does not correspond to the actual care

performed). Because of uncertainty, Reed (23) suggests that

all record data should not be treated as a source of infor-

mation in research but as a topic of study in its own right.

Data from patient records represent one type of `secon-

dary data', i.e. existing data originally collected for other

purposes than research. This means that the design and

primary collection of data are beyond the control of the

researcher. Data have been collected for other purposes, by

persons and in situations unknown to the researcher (23).

According to our ®ndings, the methods of collecting and

analysing secondary data are scarcely described in the

methodological literature. It seems that the problems

associated with the interpretation and application of record

data are largely neglected.

In nursing homes and other residential arrangements in

Swedish municipalities, health care is managed by regis-

tered nurses. The focus of care for the residents is nursing

care needs. Medical records are usually stored in primary

health care centres that are located apart from the nursing

homes. Thus, the nursing record is the basic document that

is accessible for health care, which puts special demands on

its quality and accuracy.

Aims

The aim of this paper is twofold. First, to explore different

approaches in reviewing records based on a literature

review of studies devoted to the auditing of patient records.

Second, to empirically test the various approaches to

auditing record data on a sample of patient records to

illuminate consequences of their application.

Material and methods

The method used for this study was a literature survey of

empirical studies of nursing recording. Based on the ®nd-

ings from the review, an audit was carried out on a sample of

records from nursing homes and other residential

arrangements in a municipality using the different

approaches in auditing previously outlined in the literature.

Literature search. The literature search was performed in late

1999 using the Medline (PubMed) and Cumulative Index

of Nursing and the Allied Health Literature (CINAHL)

databases. The search covered the period January 1990±

October 1999. A trained librarian assisted in the search.

The search terms used were medical records, audit and nur-

sing. The inclusion criteria were that the studies had to be

(a) published during the period from January 1990 to

October 1999, (b) be written in English and (c) geared to

an empirical review or audit of nursing content in patient

records. The search retrieved 58 citations from Medline, of

which 17 (29%) met the inclusion criteria. Forty-seven

papers were found in CINAHL and 16 (34%) of these

satis®ed the inclusion criteria. Four of these papers,

ã 2001 Nordic College of Caring Sciences, Scand J Caring Sci

134 A. Ehrenberg et al.

however, were already retrieved through Medline. Vol-

umes of scienti®c journals were also searched manually:

Quality in Health Care (1993±1999), Scandinavian Journal of

Caring Sciences (1994±1999) and Journal of Advanced Nursing

(1998±1999), yielding 20 more relevant studies. In addi-

tion, Current Contents was scrutinized for the last month in

an effort to retrieve papers not yet indexed in the data-

bases. This search did not lead to any new citations,

however. Proceedings of conferences in Medical and

Nursing Informatics were searched, including the Inter-

national Medical Informatics Association and Nursing

Informatics from 1994±1999. The manual search of pro-

ceedings added one more paper of relevance. Totally, 56

papers were included in the review.

Sample of records. In the empirical phase of the study,

patient records were collected from nursing homes and

other residential arrangements in a Swedish municipality.

Twenty-one units for the elderly with varying care

organizations and nursing staff facilities were included. A

strati®ed sample of records of patients with one of the

medical diagnoses dementia, diabetes or congestive heart

failure was selected retrospectively for a period of 2 years.

The sample was based on all patients aged 65 years or older

with current health care services. In all, 298 patient

records were included. The records were originally collec-

ted for another study (Swedish National Board of Health

and Welfare, unpublished manuscript).

Ethical considerations. In as much as all personal identi®ca-

tion was removed from the copies of the records, informed

consent from patients was not sought. Permission to con-

duct the study was obtained from the director of services

for the elderly in the municipality. The original study was

made on commission from the Swedish National Board of

Health and Welfare. It was agreed that the results from the

record review could be further used. Records were copied

either by the nurses in charge or by the researchers.

Analysis of literature. The studies were analysed with the

following structured set of questions:

1 From what type of care or speciality area were patient

records collected?

2 How large was the sample of records?

3 Were records paper- or computer-based?

4 Did the record review focus on occurrence of general

criteria, such as the phases of the nursing process?

5 Did the record review focus on criteria pertaining to

speci®c medical or nursing diagnoses?

6 Were speci®c criteria derived from research or clinical

guidelines?

7 Did the review follow the care process for single patient

problems?

8 Were recorded data compared with other sources of

data?

9 Was an analysis of outcomes of care connected to the

quality of recorded data?

Analysis of records. To gain an understanding of the effects of

the varying approaches, different methods were used to

audit the records.

1 The records were reviewed for content according to

Swedish regulations for nursing recording, corresponding

to the phases of the nursing process (24).

2 An audit instrument focusing on the comprehensiveness

of the documentation of identi®ed patient problems was

used (16). The use of the instrument has been tested in

previous studies and demonstrated good inter-rater

reliability (k � 0.93). Each patient problem is scored on a

5-point scale, where a score of 1 indicates that there is

either a description of a problem or an intervention. A score

of 2 denotes that there is a problem description and a

planned or implemented intervention, 3 indicates that

there is a description of the outcome in addition to a

problem description and a planned or implemented

intervention. If the problem is described, interventions are

both planned and implemented and outcome is noted, a

score of 4 is given. A total score of 5 indicates that all steps of

the nursing process are recorded, there is a good description

of the problem and recording is of particular relevance to

nursing.

3 The records were ®nally audited using diagnosis speci®c

criteria. Because there did not exist any evidence-based

and agreed upon criteria, the criteria were developed from

available research for this study. Comparable criteria were

chosen for all three diagnostic groups to make it possible to

compile and compare data. The response alternatives were

given on a 3-point scale, indicating that data were absent,

partly present or wholly present.

For patients with dementia, the records were reviewed

for assessment of the patient's communicative skill

regarding the ability to understand and make oneself

understood. Notes about nutritional status that focused on

eating habits and self-care status on personal hygiene and

eating were searched. The criteria for nursing interven-

tions focused on promotion of patient participation in self-

care and teaching in self-care activities (25±29).

The criteria for patients with diabetes included the

assessment of status on communicative ability, nutritional

habits and self-care activities. The criteria for nursing

interventions centred on the patient's self-control of,

e.g. blood glucose, information and teaching on self-care,

treatment, diet, exercise, prevention, drugs and complica-

tions related to the disease (30).

For patients suffering from congestive heart failure, the

following assessment criteria were used: communicative

and nutritional status and self-care activity. The criteria for

nursing interventions were promotion of participation in

self-care and information and teaching regarding diet and

treatment (31±33).

Auditing nursing records 135


Results

Approaches in auditing records

Among the 56 studies in the review, 71% (n � 40) were

conducted in hospital settings, 20% (n � 11) in primary

health care and 9% in other areas. Eighteen studies were

from the USA, 17 from the UK, 16 from Sweden, two from

Australia and one study each from Ireland, the Nether-

lands and Norway. The majority of studies (n � 52) used

paper-based patient records and four studies used com-

puterized records or a combination of both. Half of the

studies (n � 28) encompassed the recording from various

health care professionals. The number of records studied

varied between 16 and 11,246 (mean � 472, SD � 1,532).

In the review of studies we found that audits of patient

records were performed using different approaches with

varying objectives, although the objectives were not

always clearly stated. The focus of the four approaches can

be described as formal structure, process comprehensive-

ness, knowledge base and concordance (validity). The

distribution of the different approaches in auditing records

is displayed in Table 1.

Formal structure approach. At the most basic level, the

studies contained an assessment on formal aspects of the

record. These were questions concerning the adherence of

the record content to laws and regulations. For example,

the record was audited for accuracy as to signature of the

recorder, date and time, patient identity, readability and

abbreviations. The studies contained audits of the presence

of single aspects of care, such as patient assessment, diag-

nosis, care plan, implementation or evaluation. In this type

of audit, only presence or absence of the data was checked

and no judgement was made about any relation between

different pieces of information in the record or the rele-

vance regarding patient care. In some of the studies, this

approach, in addition to other approaches, was found in 19

papers during the period of the investigation (i.e. 1990±

1999) (16, 17, 34±50). Examples of audit instruments

using this approach partly or wholly are the Rush Medicus

Process Instrument (10) and NoGa (17).

Process comprehensiveness approach. At the next level, the

audits focused on the coherence or comprehensiveness of

information about the different phases of the nursing

process. This approach was used to identify to which

extent single patient problems or needs were recorded

systematically, showing the progress of the care and which

would enable overview of the care episode. However, it

does not give any information on the relevance of recorded

data for the individual patient or the relation to existing

knowledge. An instrument following this approach has

been presented by Ehnfors & Smedby (16) and further

used in seven retrospective studies of nursing recording

(35, 37, 38, 46, 47, 51).

Knowledge-based approach. In using a more advanced

approach, the goal of the audits of records was to assess the

actual relevance of the record content. The audit was

grounded on evidence-based clinical guidelines, care pro-

grammes, protocols or established criteria for speci®c

groups of patients or specialities in nursing. The focal point

of the audit was sometimes on speci®c problems or needs,

such as pain or patient education. This more speci®c

approach to monitoring patient records was found in 41

studies (18, 20, 22, 36, 37, 40, 44, 47, 50±82).

Accuracy approach. The concordance between patient record

and the actual care given can be studied in two ways. One

is to study `correctness' ± the proportion of recorded

observations that are correct, i.e. in agreement with the

patient's real situation. The other way is to study `com-

pleteness' ± the proportion of observations that are actually

recorded. When it comes to reviewing records, the two

perspectives are deemed complementary in the sense that

both are necessary for the understanding of the accuracy of

the record (3). These perspectives highlight the complexity

of this approach in reviewing records.

A few studies have been published that have concen-

trated on the accuracy of the recorded nursing data. In

total, ®ve studies using this approach were found. Dis-

crepancies have been found between the recording and

the occurrence of symptoms and problems as reported by

nurses or patients or as observed by investigators

(20, 22, 68, 83). In using this approach, concurrent or

prospective record audits and observations need to be

carried out. The accuracy of records has also been studied

in relation to secondary data in other health care registers

(84).

Empirical use of different approaches in auditing

patient records

To display the consequences of using different methods an

effort was made to apply three of these approaches on a

sample of records (n � 298) from nursing homes and

other residential arrangements in a Swedish municipality.

Table 1 Type of audit approach in studies on reviews of nursing

recording (n = 56)

Type of approach Studies n (%)

Formal structure 19 (34)

Process comprehensiveness 7 (13)

Knowledge based 41 (73)

Accuracy 5 (9)

Total 72a

a Some studies combined two or more approaches.



Because a retrospective material was used, the fourth

approach ± the accuracy approach ± was not possible to

apply. The same set of records was used for the different

approaches.

Formal structure approach. The presence of the date (day,

month and year) at all relevant places is one formal

requisite of a patient record. This was found in 271 (91%)

of the 298 records. Almost as frequent were signatures of

notes by the recorder, which were present in 256 (86%)

records. A general description of patient problems was

present in 224 (75%) of the records. Descriptions of

patient's speci®c problems related to diagnosis were pre-

sent in 218 (73%) of the records. These values are dis-

played in Table 2.

Process comprehensiveness approach. In auditing the compre-

hensiveness in the documentation of speci®c patient

problems, 383 major problems or needs identi®ed in the

298 records were scored on a 5-point scale, as described

previously. The problems that were chosen were those that

appeared to be of priority and call for care planning. The

audit showed that none of the 298 records contained a

complete documentation of any single problem. Fifty-four

(14%) of the 383 major problems were recorded according

to basic Swedish legal demands, which comprise a problem

description, planned and implemented nursing interven-

tions and evaluation of the nursing care (indicated by the

score 4). Of the 383 major problems, 126 (33%) reached a

score of 3, indicating the presence of a problem description,

a planned or implemented nursing intervention and notes

about the outcome. A little more than half (n � 203, 53%)

of the problems were recorded in such a way that the

process of care could not be traced. This means that they

scored 1 (28%) or 2 (25%) on the 5-point scale, indicating

that there was, at the most, a description of the problem

and some mentioning of an intervention (planned or

implemented) related to that particular problem (Table 3).

Knowledge-based approach. The patient records were also

audited using diagnosis-speci®c knowledge-based criteria

for the patients with dementia, diabetes and congestive

heart failure. These occurrences of diagnosis-related cri-

teria in the patient records are displayed in Table 4.

For patients suffering from dementia (n � 100), notes

concerning the patients' communicative status, i.e. the

ability to understand and make oneself understood, were

present in 15 (15%) records. Eating habits were recor-

ded in 11 (11%) records and self-care ability in 26

(26%) records. Among nursing interventions, notes

about the promotion of patient participation and in-

volvement in self-care activities were present in 12

(12%) records and teaching about self-care was recorded

in 6 (6%) records.

In patients with diabetes (n � 90), communicative sta-

tus, i.e. the ability to understand and make oneself

understood, was recorded in 10 (11%) records. Assessment

of eating habits was recorded in 11 (12%) records and

self-care ability in 19 (21%) records. Only 6 (7%) of the

records had notes about interventions to support the

patients' self-care and participation in metabolic control.

Table 2 Occurrence of some formal aspects in the records (n = 298)

Criteria Records n (%)

Date 271 (91)

Signature 256 (86)

General problem description 224 (75)

Speci®c problem description 218 (73)

Table 3 Scores for comprehensiveness in the documentation of major

patient problems (n = 383) in the records

Score Patient problems n (%)

1 107 (28)

2 96 (25)

3 126 (33)

4 54 (14)

5 0 (0)

Total 383 (100)

Table 4 Occurrence of some diagnosis-related criteria in the records (n = 298)

Subsample

Criteria Dementia (n = 100) n (%) Diabetes (n = 90) n (%) CHF a (n = 108) n (%) Total (n = 298) n (%)

Communicative status 15 (15) 10 (11) 32 (30) 54 (18)

Nutritional status: eating habits 11 (11) 11 (12) 16 (15) 39 (13)

Self-care ability 26 (26) 19 (21) 25 (23) 69 (23)

Promoting participation 12 (12) 6 ( 7) 18 (17) 36 (12)

Teaching self-care 6 (6) 2 ( 2) 2 ( 2) 9 ( 3)

a CHF = Congestive heart failure.



Even less frequent were notes about teaching self-care,

which were present in only 2 (2%) of the records.

In the assessment notes for patients suffering from

congestive heart failure (n � 108), communicative ability

was present in 30% (n � 32) of the records. Fifteen per-

cent (n � 16) had notes about eating habits. In the nursing

interventions, notes about promotion of patients self-care

appeared in 17% (n � 18) of the records. Least frequent

were notes on information and teaching the patient about

self-care, which were present in 2% (n � 2) records.

When the data from the three approaches for record

reviews were combined, a clear trend materialized.

Figure 1 depicts the proportion of records that complied

with established criteria for the three approaches on the

same material of patient records. The formal structure

approach, complying with the criteria derived from laws

and regulations, varied between 73 and 91%. When the

process comprehensiveness approach was used on the

same set of records, the percentage of records complying

with the criteria for completeness, according to the nursing

process, decreased and varied between 14 and 33%. When

the record data were analysed in relation to diagnosis-

speci®c nursing content (the knowledge-based approach),

the proportion of records complying with the criteria

decreased even more. Between 3 and 23% of the records

captured the relevant data when using the knowledge-

based approach.

Discussion

The ®ndings in this paper present a framework that can be

used for understanding different dimensions in auditing

patient care records. From our study, we de®ned four

approaches to reviewing records.

The ®rst approach of record review ± the formal struc-

ture approach ± can be seen as the most basic way of record

monitoring. It may be useful in obtaining an overview of

the current practice in recording in a very early stage of

development, but gives only a fragmented view of the

record content. Relevant data may be recorded without

being further analysed or used as a basis for decisions about

nursing interventions. This approach may give a super®cial

or a false portrait of high quality.

The next approach in reviewing records ± focusing on

the process ± provides a more solid representation of the

comprehensiveness of the record content. This approach to

auditing gives information about the degree to which the

nurse has planned, implemented and evaluated single

patient problems in recording. The focus of this approach is

on major problems of the patient that call for a care plan

and should not be applied to occasional or temporary

problems of lesser importance. In the empirical part of this

study it was used for all major patient problems identi®ed

in the records. The approach may also be used for a few

speci®c or prede®ned problems of interest, e.g. pain or

patient participation. It does not impart answers about the

relevance of the recorded data for the patient or the actual

quality of care, but it does reveal the logical ¯ow and the

completeness of events in care.

In the third, more speci®c approach to monitoring

the records, the focus is on pertinent information for

the patient. This approach was most commonly used in the

studies of this review. Such a method may be useful for

quality improvement purposes as it facilitates in providing

an overview of current practice in relation to relevant

knowledge. Evidence-based clinical guidelines need to be

developed to serve as a basis for audits using this approach

as well as for the development of patient care itself.

The ®rst three approaches to monitoring records des-

cribed above require only access to the patient record, and

thus can be performed retrospectively. To challenge and

secure the validity, reliability and effectiveness of the

recording, concurrent and prospective studies are needed

that include the patient as well. The concordance between

the content of the record and the actual situation of the

patient and the care given has been questioned. Accord-

ingly, another approach to auditing nursing records is to

study the concordance of the record with the patient's

actual situation and needs and to concomitantly critically

examine the basis for the interventions undertaken. This

approach was not possible to test in this study in that a

retrospective record material was used.

In the empirical part of the study, the use of the formal

structure approach revealed that descriptions of patient

status were quite frequent, appearing in about three-

fourths of the records. When applying the process-focused

approach to the recorded data, a little over half (53%) of

the patient problems lacked a comprehensive documen-

tation. This made it impossible to follow the process of care

(i.e. scoring <3). It appears that the process-focused

approach exhibits a more in-depth representation of the

recording. When auditing only the structure of the

recording, there is a risk that the record appears to be of

better quality than what is actually the case. The know-

ledge-based approach revealed that the diagnosis speci®c

criteria, for all three diagnostic groups studied, were

recorded in less than or about every ®fth record. Because

there was no concurrent observation of the actual needs

and problems of the patients in this study, it is not known

if these criteria were relevant for all patients in this con-

dition. Nonetheless, our assumption is that the criteria

represent basic data that should be present in all patient

records.

Publications on record audits are not easy to come across

in scienti®c databases because of lack of standardized

indexing. The literature search may have detected addi-

tional studies if the search strategy had been altered and

broadened. The empirical testing of the different approa-

ches to auditing records was carried out on records from

nursing homes and other residential arrangements only.



It is possible that the ®ndings from this part of the study

could be altered if applied in other areas of care. The

empirical testing was performed using paper-based patient

records. Computerized patient records may also in¯uence

the ®ndings of the application of the different approaches

in auditing records.

Despite the problems in using secondary data, the

patient record may be a useful source of information in

research and development. If record data are to be used,

it is necessary to consider the problems of validity and

reliability and to critically choose the most appropriate

methods for auditing. In this review of studies, there was

a complete lack of discussion on the validity of the recor-

ded data in 20 (36%) of the papers; despite this ¯aw,

conclusions about the quality of care were made from the

®ndings of these studies.

The conclusion of the present study is that audits of

patient records should not be limited to encompass the

formal structure of recording. To gain a more complete and

reliable picture of the quality of recording we suggest the

process comprehensiveness approach in combination with

a critical review of the knowledge base for assessment,

diagnosis, interventions and outcomes of patient care in

the records.

The question of whether the use of individualized care

planning and systematic recording contribute in a signi®-

cant way to a high quality of care standard is still unan-

swered, as is also the case of whether the record, in general,

validly re¯ects the patient's situation and care. Studies are

needed that use different approaches in order to accept or

reject the assumption that individualized care planning and

practising the nursing process format accurately re¯ects the

care and contributes to the quality of care.

Acknowledgements

This work has been supported by grants from the Swedish

Foundation for Knowledge and Competence Develop-

ment, the Swedish Society of Nursing, Department of

Public Health and Caring Sciences, Uppsala University and

the Swedish National Board of Health and Welfare. We

wish to acknowledge Dan Andersson, Kerstin Nordstrand

and Frans Prenkert for contributing to the empirical part of

the study and Leslie Shaps for language revision.

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