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:: Volume 1, Issue 3 (12-2012) ::
مدیریت پرستاری 2012, 1(3): 37-45 Back to browse issues page
Assessing quality of nursing documentations and effective factors on it in medical-surgical units
Madineh Jasemi * , Alireza Mohajal Aghdam , Azad Rahmani , Farahnaz Abdollahzadeh , Vahid Zamanzadeh
Nursing & Midwifery School, Tabriz University of Medical Sciences, Tabriz, Iran , jasemi_master@yahoo.com
Abstract:   (22664 Views)

Introduction: Nursing documentations are signs of nursing care implementation. Follow the principals of documentation could be effective for patients’ safety nurses’ security.

Aim: This study was done for Assessing quality of nursing documentations and effective factors on it in medical-surgical units.

Method: This study was descriptive- corollative that was done in 2010.All of nurses in medical and surgical units in teaching hospitals (170) were in this study and also, 2040 documents selected simple randomly which they were in four domain in nursing nursing record, check vital signs , intake & output and drugs administration. They were observed by checklist. Reliability was 88% by inter-rater observers. Nurses’ attitude, their knowledge and viewpoints about the quality of effective factors on nursing documentation were assessed by questioners. Reliability of knowledge questioner was 0.97% by using Kuder Richardson 21. Reliability of attitude questioner was 0.90% by using test –re test. Also, this test showed that reliability of questioner for assessing quality of effective factors was 0.91%. Validity all of the questionnaires was assessed by content validity. Data analyzed by Pearson test, One-way-ANOVA and T test by SPSS software.

Results: The results showed that 100% of nursing record and vital sign charts had average level of quality, 85.9% of drug administration and 81.2% of I&O of fluids domains had good level of quality. 85.1% of nurses had average level of  knowledge and 99.5% of  them had positive attitude toward nursing documents  and viewpoint of 78.4% nurses  about quality  of management’ factors were average level. There were significant relationships between kind of units, hospital and experience with quality of nursing’ documents (p<0.001 (gender and quality of nursing’ documents (p=0.003) and age with nursing’ documents (p=0.006).

Conclusion: It is recommended that hospitals improve necessary conditions for corporation, motivation, organizational communication, and education for nurses. In addition, it is recommended to nurses who are knowledge worker improve their individual skills and team-work capabilities to increase their competence and job satisfaction.

Keywords: nursing documents, medical-surgical nursing, quality of nursing documents
Full-Text [PDF 591 kb]   (2964 Downloads)    
Type of Study: Research | Subject: Special
Received: 2012/09/8 | Accepted: 2013/10/6 | Published: 2013/10/6
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Jasemi M, Mohajal Aghdam A, Rahmani A, Abdollahzadeh F, Zamanzadeh V. Assessing quality of nursing documentations and effective factors on it in medical-surgical units. مدیریت پرستاری 2012; 1 (3) :37-45
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Volume 1, Issue 3 (12-2012) Back to browse issues page
فصلنامه مدیریت پرستاری Quarterly Journal of Nursing Management
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