An analysis of nursing documentation of COPD's patient records in the Inpatient Department, Tha Sae hospital, Chumphon Province.

Abstract

              This study reviewed a COPD's patient records with purpose of the study were 1) to analyze a nursing documentation of COPD's patient records on 4 contents,including patient assessment, nursing plans,nursing implementation and nursing evaluation 2) to analyze a quality ofnursing documentation ,including correctness, completeness ,clearness and conciseness. The sample of the study consisted of 224 COPD's patient records files in Inpatient Department, Tha Sae hospital, Chumphon Province,during 1October 2014 to 30 September 2015.They were divided in 2 groups,194 fines for sampling and 30 fines for testing. Research tools of the study consisted of 1) General questionnaire, 2)APIE (Assessment, Planning, Implementation, Evaluation) questionnaire and 3) 4C (Correct, Complete, Clear and Concise)questionnaire. The surveying by using these 3 research tools were analyzed by statistics value that comprising, frequency ,mean and standard deviation value.
              The results of this study showed that a completeness of the patient records data on general questionnaire was indicated by 97.42 %. By 82.50% of the patients was male , that 95.88% of them have a dyspnea and 75.77% of them was smoking. Whereas a completeness of the patient records data on APIE questionnaire was indicated by 66.49% that consisted of 1) An assessment of the patient's disease, the Gordon's form was usually used that indicated by 99.15% 2) A nursing planning, there was 5 notes for nursing planning ,such as activity intolerance ,infection, lack of knowledge of disease ,risk for infection andanxiety. 3) A nursing practice, there was 10 activities, such as check vital signs, medication management,assessing symptom control, observing sign ,hygiene care, administering antibiotic,fluid therapy,rest,positioning patient and other caretaking 4) An assessment of nursing resulf, there was maximum value of a conclusion and recommendation for patients and their family that was indicated by 93.30% while, there was a minimum value of referral system and home care that were indicated by 27.32% and 4.12%,respectively. Finally, the results of examination of nursing document in the patient records
by using 4C questionnaire was medium quality (3.42) that comprising high correct value (3.76) and medium complete, clear and concise value (3.22,3.37 and 3.32 respectively)
              The results could be concluded that personnel development program should be established to increase the knowledge and capability levels of the professional nurses regarding the nursing documentation, create incentive and motivation for the nurses to be more aware of the importance of nursing documentation and manual for documentation. There should also be a system for the evaluation of nursing documentation should also be in placed in order to establish a quality control system for nursing documentation which they could be increased the effectiveness of hospital 's management for the future.