Development of nursing documentation on focus charting nursing

Abstract

Objective : 1. To develop a nursing record system 2. To study nurse satisfaction of nursing record system and 3. To improve the quality of nursing records. 

Methods : This study is research and development method. The population included 12 registered nurses who work in intensive care units at Bangkok Hospital Khon Kaen. The tools was developed and approved from three experts yielding. Content Validity Index (CVI) was 0.932. The reliability of the questionnaire was analyzed by Cronbach's alpha coefficient which was found at 0.913. Data analysis was performed by frequency, percentage, mean and standard deviation. The difference in nurse satisfaction was analyzed using statistics. Paired t-test the level of statistical significance at the level of 0.05.

Result : The study results revealed that the intensive care unit has nursing documentation and recording system of nursing care which is patient specific care plans. Nurse satisfaction with nursing record system in 3 aspects, overall were found at a high level ( = 4.04, S.D. = 0.62). The first aspect is beneficial of patient of nursing care plans, second aspect is time-saving and convenient, and the last aspect is nurse satisfaction with record system were at high levels ( = 4.24, 3.80, 4.00 respectively; S.D. = 0.57, 0.98, 0.82, respectively). Reducing the time of written work load of nursing care plans average 2.67 minutes (27%). The quality of nursing records 84.13%, t-test -0.410 (p-value = 0.772).

Conclusion : The results of this study can be used to reduce the time of written work load of nursing care plans. The registered nurses were satisfied, while the quality of nursing documentation and recording systems need to be develop by improving Web-Based Nursing and Hospital Information System (HIS).