Nursing documentation audit – the effect of a VIPS implementation programme in Denmark

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Abstract

Aim and objectives

The aim of this paper is to present a study describing nurses' adherence to the VIPS model by evaluating the quality of nursing assessment, and the quantity of completed nursing care plans.

Background

Numerous efforts have been made over the years to improve nursing documentation in Denmark. Hospitals have traditionally based nurses' charting on a rudimentary version of the nursing process and on Virginia Henderson's theory of human needs. In 2002–2004 the Copenhagen University Hospital, Rigshospitalet, introduced the Swedish VIPS model for nursing documentation. VIPS is an acronym for well being, integrity, prevention and safety, all of which are seen as major goals for nursing care. The model organizes nursing data according to a system of keywords, which facilitates storage and retrieval of data.

Design and methods

The design in this part of the study was retrospective, wherein 50 journals from each of the departments of cardiology, neurology, oncology and urology were audited annually for three years using the Cat-ch-Ing instrument (n = 600). All nursing journals were randomly selected by including the first 50 journals at each site given a specific date.

Results

The nursing documentation significantly improved during the course of the study. After the second year the participants used the keywords appropriately and correctly according to the VIPS model. Application of primary nursing increased during the study. Initial, ongoing and discharge patient status improved. The nurses' familiarity with nursing diagnoses, goals and interventions increased.

Conclusions

The structured implementation programme significantly improved nursing documentation, and the simultaneous training of the entire nursing staff shows promise. The VIPS model has prepared the nurses for more complex computerized taxonomies and classification systems in the future by improving the nurses' analytical skills.

Relevance to clinical practice

New strategies for improving nursing documentation have been demonstrated.

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