Content validation of an instrument for medical record audits

Methodological study conducted from May/2020 to May/2021 in three stages: 1) development of the instrument by bibliographic survey and benchmarking; 2) content validation using the Delphi technique; 3) application of the instrument and descriptive analysis in a sample of 200 medical records.

Results:

An instrument was constructed with 11 domains containing sub-items that characterize the quality of care. Two stages of the Delphi technique were necessary to reach a content validity index higher than 0.90. For each domain, a graduated scale with a numerical value from 1 to 4 points was attributed, reflecting the quality of its completion. The average time of application was 35 minutes per record.

Conclusions:

The tool proved to be viable to support clinical audits to identify the level of excellence and reveal opportunities for improvement in care processes.

Descriptors:
Patient Safety; Medical Records; Validation Study; Total Quality Management; Clinical Audit

Domain	Phase I Delphi	Phase II Delphi
Patient Identification	1.0
Actual Communication	1.0
Safety in Medication Prescription, Use, and Administration	1.0
Safe Surgery	1.0
Device-Related Infections	0.86	1.0
Managed Care Risks	0.86	1.0
Guideline-Based Protocols	1.0
Medical Procedures	1.0
Nursing Procedures	1.0
Multidisciplinary Team Actions	0.86	1.0
Safety Culture	0.86	1.0

Item/information	1^* * Lack of information; + Inaccurate and/or incomplete information; ǂ Clear but incomplete information; § Accurate and complete information; ǁ Not applicable.	2+	3ǂ	4§	NAǁ
Patient Identification
Admission form	0	0	0	100	0
Exhibition of an identification wristband	5.5	42.5	42	10	0
Documents completed with patient identification	0	12.5	52.5	35	0
Signed Informed Consent Form	1.5	1.5	0	97	0
Clear reason for admission	0	0.5	0.5	99	0
Therapeutic plan at admission	13.5	18.5	4.5	63.5	0
Other patients' documents in the medical record	0	0	0	0	100
Actual Communication
Communication process between sectors (transition of care)	2.5	4.5	15.5	77	0.5
Records of the interdisciplinary visit	6	12	23.5	58.5	0
Safety in Medication Prescription, Use, and Administration
Medication reconciliation by a pharmacist (first 24 hours)	71	6.5	14	8.5	0
Reconciled prescription drugs	71.5	9	11.5	8	0
Double-checking of high surveillance drugs	35	37	24	4	0
Safe Surgery
Informed Consent Form for surgical procedures	1.0	3.0	6.0	58.5	31.5
Informed Consent Form for anesthetic procedures	0.5	1.5	4.5	38	55.5
Surgical description	19.5	0.5	1.0	47.5	31.5
Safe Surgery Checklist	0	0	3.0	65.5	31.5
Evidence of surgical antibiotic prophylaxis (up to 60 minutes before the surgical incision)	0.5	0	0	40.0	59.5

Item/information	1^{^* * Lack of information; + Inaccurate and/or incomplete information; ǂ Clear but incomplete information; § Accurate and complete information; ǁ Not applicable.}	2⁺	3^ǂ	4^§	NA^ǁ
Device-Related Infection Prevention Measures
Ventilator-associated pneumonia	0	3.5	3.5	2.5	90.5
Central venous catheter bloodstream infection	0.5	11	3.5	1	84
Urinary tract infection associated with the use of indwelling urinary catheter	0	19.5	12	4.5	64
Managed Care Risks
Braden Scale	0	0.5	2	97.5	0
Morse Scale	0	0.5	0.5	99	0
Identification of risk for bronchoaspiration	2.5	1	0	92.5	4
Prevention measures for thromboembolism	9.5	0	0.5	0	90
Bleeding surveillance in surgical patients	0.5	1	0.5	68.0	30.0
Delirium during hospitalization	48.5	9.5	2	23	17
Clinical Deterioration	0	0	0.5	0.5	99
Prescription of preventive measures	0	20	27	53	0
Record of preventive measures	0	2.5	19	78.5	0
Guideline-Based Protocols
Criteria for stroke identification	0	0	0	10	90
Criteria for identifying chest pain	0.5	0.5	0	18.5	80.5
Eligibility criteria for palliative care	0.5	0	0	3	96.5
Protocols managed at recommended times	0	2	0.5	25.5	72
Guideline-based protocols related to the principal diagnosis	0.5	0	0	3.0	96.5
Guideline-based protocols with same outcomes	0	0	0	31	69
Outcome in accordance with primary diagnoses	0	0.5	0	99.5	0

Item/Information	1^{^* * Lack of information; + Inaccurate and/or incomplete information; ǂ Clear but incomplete information; § Accurate and complete information; ǁ Not applicable.}	2⁺	3^ǂ	4^§	NA^ǁ
Medical Procedures
Description of the reason for hospitalization at admission	0	0.5	0	99.5	0
Medical evolution coherent with the therapeutic plan	2	10.5	7	80.5	0
Discharge summary with clear information about what happened with the patient during hospitalization	2.5	2	1	94.5	0
Medical prescriptions carried out every day during hospitalization	0	0	0	100	0
Nursing Procedures
Care plan carried out by the nursing team	1	0	0	99	0
Clear nursing care plan, related with the reason for hospitalization	0.5	15.5	27	57	0
Nursing process applied every day of hospitalization	0	0.5	0.5	99	0
Multidisciplinary Team Actions
Prescribed physical therapy is registered in the evolution of the attention	1.5	0	12	86.5	0
Prescribed speech therapy is registered	57	21.5	5	8.5	8
The evolution of occupational therapy care is registered	0	0	0	0.5	99.5
When there is nutritional evaluation, records are made in case of nutritional risks	47	1	0.5	3.5	48
Psychological attention, when requested, is registered	11.5	0.5	1	0.5	86.5
Social services, when requested, are registered	0	0	0	0	100
Safety Culture
Are patient safety protocols respected?	0	17	46	37	0
All printed copies of the records are signed by the professional responsible for care	0	4	11	85	0
Is there evidence, in the medical records, of complications or adverse events?	0	0	0	4	96

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Corresponding author: Carla Simplicio, E-mail: carla.simplicio@gmail.com