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Mohammad Ghasaby M, Masudi Alavi N. Quality and barriers against nursing documentation in Kashan Shahid Beheshti Hospital( 2011). , Mod Care J. 2012; 9 (4) :336-343
URL: http://mcj.bums.ac.ir/article-1-448-en.html
URL: http://mcj.bums.ac.ir/article-1-448-en.html
1- Nursing Student, Student Research Committee, Kashan University of Medical Sciences, Iran
2- Associate Professor, Trauma Nursing Research Center, Kashan University of Medical Sciences. Email: masudialavi_N@kaums.ac.ir
2- Associate Professor, Trauma Nursing Research Center, Kashan University of Medical Sciences. Email: masudialavi_N@kaums.ac.ir
Abstract: (311 Views)
Background and Aim: Accurate and complete documentation of nursing reports is the precondition for evidence-based care and one of the most important duties of nurses. Besides, it has a decisive role in the quality of nursing care and improves the relationship with other health team members. The object of the present survey was to evaluate the structure and content of nursing reports and reasons of incorrect reporting in Shahid Behashti hospital of Kashan in 2011.
Materials and Methods: In this cross-sectional study, 140 nursing documents were evaluated. The records were randomly selected from the intensive care unit, internal medicine ward, and surgery ward. A 38-item checklist designed according to the eleven principles of nursing documentation was used in order to evaluate the quality of nursing documentation.In the checklist, 30 items referred to content and 8 referred to the structure of documentation. To pinpoint barriers in nursing documentation, a previously self-designed questionnaire was applied. The obtained data was analyzed in SPSS software (V:11.5 ) using statistical tests and Chi-square at the significant level P<0.05.
Results: From among the documents, 21.4% had a favorable quality, 53.6% had moderate quality, while the quality of 25% was weak. In the hospital mentioned, total content quality of nursing documents was low but that of structure was acceptable. According to the nurses, nursing staff shortage, fatigue, high workload,the documentation's on job promotion, nurses' priority to patient care rather than documentation, occupational problems, lack of knowledge of the principles of writing correct documentation, and unawaveness of legal consequences were the most frequent reasons for or barriers against accurate and due documentation.
Conclusion: The content of nursing documents was not satisfactory and requires improvement.
Materials and Methods: In this cross-sectional study, 140 nursing documents were evaluated. The records were randomly selected from the intensive care unit, internal medicine ward, and surgery ward. A 38-item checklist designed according to the eleven principles of nursing documentation was used in order to evaluate the quality of nursing documentation.In the checklist, 30 items referred to content and 8 referred to the structure of documentation. To pinpoint barriers in nursing documentation, a previously self-designed questionnaire was applied. The obtained data was analyzed in SPSS software (V:11.5 ) using statistical tests and Chi-square at the significant level P<0.05.
Results: From among the documents, 21.4% had a favorable quality, 53.6% had moderate quality, while the quality of 25% was weak. In the hospital mentioned, total content quality of nursing documents was low but that of structure was acceptable. According to the nurses, nursing staff shortage, fatigue, high workload,the documentation's on job promotion, nurses' priority to patient care rather than documentation, occupational problems, lack of knowledge of the principles of writing correct documentation, and unawaveness of legal consequences were the most frequent reasons for or barriers against accurate and due documentation.
Conclusion: The content of nursing documents was not satisfactory and requires improvement.
Keywords: Nursing Records, Forms and Records Control
Article Types: Research Article |
Subject:
General
Received: 2012/09/8 | Accepted: 2013/01/30 | Published: 2013/02/20
Received: 2012/09/8 | Accepted: 2013/01/30 | Published: 2013/02/20
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