The development of a nursing document model for the obstetrics and gynecology department at Uthai Thani hospital


  • Panee Wiruchagool Master of Nursing Science in Nursing Administration, Sukhothai Thammathirat Open University
  • Boontip Siritarungsri School of Nursing, Sukhothai Thammathirat Open University
  • Aree Cheevakasemsook School of Nursing, Sukhothai Thammathirat Open University
  • Yuwadee Ketsampan Independent Scholar


nursing document model, focus charting, quality of nursing record, satisfaction


The purposes of this research and development were: 1) to analyze the problems of nursing documents at the Obstetrics and Gynecology Department in Uthai Thani Hospital, 2) to develop the nursing document model, and 3) to evaluate the model development and implementation. The sample groups were selected by purposive sampling, including 10 nursing administrators who supervised nursing documents, and 10 registered nurses, as well as 10 professional nurses who worked at the Obstetrics and Gynecology ward.  The research tools comprised: 1) Experimental tools included a workshop project on the nursing document record, and a handbook for writing nursing documents (Focus Charting).  2) Data collection tools included: (1) a focus group guideline, (2) a form for nursing document analysis, (3) questionnaires of attitude of writing nursing documents, (4) an evaluation form for evaluating the quality of nursing documents, and (5) nurses’ satisfaction questionnaires of using the nursing document model. Data were analyzed by descriptive statistics, and Wilcoxon Signed Ranks Test.

Research findings were as follows. 1) The problems of nursing documents forms were unclear, not responding to record on breastfeeding, discharge, and nursing monitoring. Nursing record method were not accuracy and uncompleted. 2) The developed model comprised 5 forms; (1) an evaluation form for breastfeeding, (2) an evaluation form for LATCH, (3) a table showing Tongue-Tie (4) a discharge plan form, and (5) a nursing monitoring form. 3) The mean score of attitude and quality on recording nursing documents were statistically significantly higher than before using a model (p<.05).  Nurses rated the satisfaction of nursing document model at the high level (Mean = 4.12, SD =.51). 

Recommendation: The developed model can be used as a guideline to develop a nursing document model of others nursing departments that are similar contexts.


Pongphanpisan P. Laws and records Documents. Meeting for lecturing at an academic conference Nursing Association of Thailand, Northern Branch 2011. (in Thai).

Blair W, Smith B. Nursing Documentation: frameworks and barriers. Contemp. Nurse.2012 [cite 2019 May 25]; 41, 160-168. Available from:

Ketsamphan Y. Focus charting: patient centered document. Meeting 14th HA National Forum; 2013 Mar 12-15; at IMPACT Convention Center Muang Thong Thani Nonthaburi; Faculty of Medicine Siriraj Hospital. (in Thai).

Brady LC. Documentation systems. In k. Stout (Ed.), Nursing Documentation made Incredibly Easy! 5th Edition. Philadelphia: Wolters Kluwer; 2019. p. 72-74.

Teerakul P. Effects of using the focus charting nursing documentation on quality of nursing perceived by patients, and professional nurses’ satisfaction using the focus charting nursing documentation [Master Thesis of Nursing Science].Bangkok: Chulalongkorn University; 2015. (in Thai).

Moonmunkol M, Sripusanapun S, Sittiwankul C, Tananuchittiku Y. Results of using focus charting nursing record In Patient Department at Lampang Hospital. Journal of Health Science 2017; 26(2): 410-17. (in Thai).

Cheevakasemsook A, Moolsart S. Noimuenwai P. Apply research findings subject: Development of a Nursing record model on the use of nursing process Lam Luk Ka hospital to provide academic services to society. Nonthaburi: Sukhothai Thammathirat Open University; 2013. (in Thai).

Komlomlird U. The development of a nursing record model in a neonatal intensive care unit of Samutsakhon hospital [Master Thesis of Nursing Science]. Nonthaburi: Sukhothai Thammathirat Open University; 2012. (in Thai).

Nursing department Uthai Thani hospital.Document record examination score summary report: Classified by department (2015-2019). Uthai Thani: Uthai Thani hospital; 2019. (in Thai).

Pattharamongkolkhet V, Boonmee P. Development of nursing documentation on focus charting nursing Record in Inpatient Units at Maechan Hospital, Chiang Rai province. Journal of Nursing Public Health and Education 2017; 18: 123-36. (in Thai).

Nursing Department Siriraj Hospital. Focus charting: a case study of a Siriraj hospital. Documentation for lectures academic forum of the department of Siriraj nursing hospital. Bangkok: Siriraj hospital; 2013. (in Thai).

Punthasee P. Namjuntra R. The development of nursing process based documentation. Nursing Journal 2012; 21: 80-93. (in Thai).

Gibson, JL, Livancevich JM, Donnelly JH Jr. Konopaske R. Organization: behavior, structure, processes. 14thed. Boston: Mc Graw-Hill; 2012.

Insorn S. Development of Nurses Notes Model by Using the Nursing Process for the In-Patient Department at Rasisalai Hospital, Srisaket Province [Master Thesis of Nursing Science]. Nonthaburi: Sukhothai Thammathirat Open University; 2014. (in Thai).

Ongjui W. The results of the development of a nursing record model Wapi Pathum Hospital, Maha Sarakham Province [Master Thesis of Nursing Science]. Nonthaburi : Sukhothai Thammathirat Open University; 2015. (in Thai).




How to Cite

Wiruchagool P, Siritarungsri B, Cheevakasemsook A, Ketsampan Y. The development of a nursing document model for the obstetrics and gynecology department at Uthai Thani hospital. Thai J. Cardio-Thorac Nurs. [Internet]. 2022 Mar. 12 [cited 2024 May 22];32(2):186-201. Available from:



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