الفهرس | Only 14 pages are availabe for public view |
Abstract Quality nursing documentation facilitates continuity and individuality of care, and safety of patients. The aim of this study was to assess the quality of nursing documentation in critical adult care units in Suez Canal . University hospitals. This descriptive cross-sectional study was conducted in the adult critical care units at Suez Canal University hospitals on 50 bed side nurses and 90 nursing records. The data collection tools consisted of an audit checklist for patients’ records and a self- administered questionnaire for nurses. The fieldwork lasted from October to January 2013. The study revealed thatthe nursing documentation in the study setting is generally deficient. Some of the areas of documentation demonstrate high performance such as patient’s demographic data, general rules, admission assessment, vital signs, blood glucose, syringe pump, TV fluids intake, tube feeding, oral intake, and patient’s turn position record. Other areas show deficiencies such as total fluid balance, total assessment, and blood transfusion. The most common problems from nurses’ viewpoints are the time constraints, and thus the underlying factors are nurses’ shortage and high workload. For improvement, there should be periodic review of nursing formats and orientation about nursing documentation for new nurses. The study recommends revision of the workload, review of the documentation formats, and staff development programs, with a procedure manual. Close supervision with periodic checks and audits need to be done. The use of electronic medical records and documentation should be thought in future plans. Further research is suggested to test the effectiveness of educational and training interventions on the quality of nursing documentation in ICUs. |