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Keywords:

  • audit;
  • chest pain;
  • critical pathway;
  • nursing assessment;
  • nursing process;
  • nursing records

The quality of nursing and medical records has been a source of concern for many years ( Audit Commission 1995). This study has two main purposes: firstly, to design an audit questionnaire to evaluate the quality of nursing assessment records of patients with chest pain; and secondly, to make some tentative conclusions about the quality of nursing assessment of patients with a chest pain in order to pinpoint areas that need further study. A sample of 30 patients was selected for this study on the basis of some well-defined inclusion criteria. The nursing assessment notes of these patients were evaluated using the audit questionnaire. It was found that the questionnaire was effective in gleaning appropriate information from the nursing notes to be able to derive some tentative conclusions about the quality of nursing assessment of patients with chest pain, i.e., on the whole nursing assessment was found to be superficially carried out, potentially making errors of omission and commission likely to occur. The inter-rater reliability of the questionnaire was found to be good. The questionnaire also seems to measure what it purports to measure (i.e. has content validity). However, this needs to be further checked by using a larger sample.