الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 188 |  |  |
| | | from | 188 | | |
Abstract
Documentation is a communication method that confirms the care provided to the client and clearly outlines all important information regarding the client. Documentation of nursing care is a very important aspect of every nurse’s job as the old saying “if it is not documented it is not done”.
This study aimed to assess factors affecting nurses’ performance regarding documentation in surgical units through; assessing nurses’ knowledge about documentation, assessing nurses’ performance in relation to documentation, and identifying factors affecting nurses’ performance regarding documentation.
The subjects of this study were eighty nurses who working at El- Demerdash University Hospital in the surgical units. Two tools were used for collecting data: (I) self administered questionnaire sheet: which divided into three parts: 1st Part: aimed to collect socio demographic data about study subject such as; age, sex, qualification, years of experience, and attending training program. 2nd part: It aimed at assessing nurses’ knowledge about documentation, it include accuracy, signature, timing, and other items. 3rd Part: it aimed to assess factors affecting nurses’ performance regarding documentation, it was divided into 8 factors as; administration
Summary
118
and hospital system factors, organization support factors, personal factors, work environment factors, leadership factors, resources factors, communication system factors, and staff development factors. (II) Analysis for nurse’s performance in the patient files by retrospective audit by the researcher reviewing files.
The present study revealed that the following main results:
- All nurses had satisfactory knowledge regarding accuracy
related to items of use pen in writing and clear hand writing.
- (98.75%) of nurses were satisfactory knowledge regarding
accuracy related to items of use simple language, and record
information understandable for the medical team.
- The majority of nurses were having satisfactory knowledge
regarding accuracy related to writing in concise manner and
erasing and crossing in record, while 87.50% were related to
use of abbreviations approved by hospital policies.
- The majority of the study subjects were having satisfactory
knowledge regarding timing related to data registration
which directly contribute to the evaluation process and the
registration of events as they occur (96.25% & 95.00%
respectively).
- More than three quarters of the study subjects (75.50%) were agreed upon personal factors related to the administrative
Summary
119
functions overlap with the responsibilities of nurse, and (72.00 %) of them were agreed upon the clarity of the line when writing nursing care.
- More than three quarters of nurses agreed upon work
environment factors related to increased work load for
nurses, shortage of nurses’ in department, multiple
registration forms per patient.
- More than four fifth of the study subjects agreed upon staff development factor related to the existence of training courses on nursing record for newly appointed nurses, and the existence of educational program for the use of different forms for registration in the medical file.
- The findings of the current study revealed generally inadequate nurses’ performance regarding documentation.
- More than three quarters of nurses had inadequate performance related to clear hand writing (76.50 %), and drawing line through the blank spaces (74%).
- About three quarters of the study subjects have inadequate performance among different items of timing.
- The majority of nurses’ had inadequate performance related to correct error with no signature and correct error by making single line marked on it 80.50% & 77% respectively.
- (75%, 74.50%) of nurses’ had inadequate performance related to keeping records in a private place. 77% of the study
Summary
120
subjects had total inadequate performance regarding documentation.
- There were no statistically significant relations between nurses’ knowledge and their socio-demographic characteristics; also, there were no statistically significant relations between factors affecting nurses’ and socio-demographic characteristics. The results revealed also, no relation detected between nurses’ knowledge and their performance.
- To conclude, the overall factors affecting nurses’ performance regarding documentation in surgical units were as follow: the majority of them (98.75%) had satisfactory knowledge regarding documentation, and (77%) had inadequate performance regarding documentation. Also, the most contributing factors affecting nurses’ performance regarding documentation as reported by staff nurses; shortage of staff nurses, work overload, multiple registration forms per patient, need to educational program for the use of different models for registration in the nursing records.
- Based on the results, the study recommended that the need for developing of an electronic information system for the nursing documentation; the current formats of nursing records to be revised and updated.