johnson m., jefferies d. & langdon r. (2010) Journal of Nursing Management
The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool
Background The Nursing and Midwifery Content Audit Tool (NMCAT) was developed to monitor the quality of nursing documentation.
Methods A health care record audit was conducted on 200 records. Using a time-sampling approach, recent nursing documentation was examined. Inter-rater reliability was determined at 85% agreement between two raters.
Results The NMCAT criteria relating to the recording of the patients’ health status, use of objective information and logical presentation were met to a high level. The patients’ response to treatment or nursing interventions including medications requires attention. The recording of events immediately after they have occurred was limited. The structure of the sentences and language used, restricted the readability of the documentation. The widespread use of local abbreviations, often connected together to form the text, was problematic.
Conclusions The present study provides new audit solutions based on time-sampling approaches and focused evidence-based criteria. The use of language support software and writing coaches to improve the presentation of nursing documentation is recommended.
Implications for Nursing Management The NMCAT is a time-efficient tool available to managers for monitoring the quality of nursing documentation, either at a unit level or across health facilities to demonstrate compliance with quality standards.