Problems and Needs of Nursing Documentation in Suddhavej Hospital, Faculty of Medicine, Mahasarakham University

Abstract

Objective : To study problems and needs of nursing documentation in Suddhavej hospital.

Methods : This study was descriptive study. The sample consisted of 27 nurses, 4 doctors and 30 patient profiles studying in inpatient wards, Suthavej hospital. The research tools consisted of the 1) Assessing the Quality of the Nursing Record Form which had Interrater reliability of > .8, 2) Group Discussion Questionnaires, and 3) an In-depth Interview Form. Data were analyzed by using frequency, percentage, standard deviation, and content analysis

Results: The results of the study as follows;1. Problems of nursing records were; 1) for assessing the quality of nursing documentation, most of all items were scored at level 1. It meant that recording was not clear, incomplete, and inaccurate (> 80 %) 2) for group discussion, there were 4 problems related to 1) the nursing documentation forms, 2) how to write in the form, 3) ability to write of the nurse, and 4) evaluation and audit.          2. The needs for nursing documentation were; 1) to develop for writing competency by having an expert to teach how to write correctly, 2) improving the nursing documentation form, 3) having the assessment, and 4) having an audit system.    

Conclusion: The results of the research indicate that there were problems with the nursing documentation of the inpatient wards in Suthavej hospital. Therefore, the nursing administrators should provide policies for improving the quality of nursing documentation according to the problems and needs of nursing using participation of the nurses.