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

Abstract

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.