Proceedings of the 15th International Academic Conference, Rome

THE EFFECTIVENESS OF USING DEVELOPED NURSING DOCUMENTATION ON NURSING DOCUMENTATION QUALITY AND PROFESSIONAL NURSES’ SATISFACTION IN THE SURGERY INPATIENT DEPARTMENT, MAHARAJ NAKHON SI THAMMARAT HOSPITAL, THAILAND

PORANEE RATTANASIRI, JANWAMOL PHANGYOTA, YUWADEE WITTAYAPUN

Abstract:

The quality of nursing documentation is an important issue for nurses to achieve patient outcome goals. The nursing documentation has constantly developed to increase accurate and legally prudent documentation. The purposes of this quasi-experimental research were: (1) to study the effectiveness of using developed nursing documentation on nursing documentation quality and (2) to study the satisfaction of professional nurses in using them. The first sample comprised 348 nursing documentation samples in the surgery inpatient department, including 174 documentation samples before and 174 documentation samples after using developed nursing documentation. The simple random sample was used to select sample. The second sample comprised 101 professional nurses working in the surgery inpatient department. The instruments used in this study included I) the developed nursing documentation, including (1) a form for nursing care plan and (2) a form for nursing progress notes (3) the nursing documentation audit form II) the nursing documentation manual and III) a questionnaire of professional nurses’ satisfaction in using the developed documentation. All instruments were approved for content validity by 3 experts. The Cronbach’s alpha coefficient of professional nurses’ satisfaction was 0.97. The implementation was applied for 3 months in 3 surgery inpatient wards. Data were analyzed using mean, standard deviation and independent t-test. The study showed that: 1) the mean quality of the nursing documentations after using developed nursing documentations was significantly higher than that before the experiment (p<.05).The professional nurses’ satisfaction regarding using the developed nursing documentation was at a high level (mean =3.41, sd =.51). The result suggested that the developed nursing documentation and the nursing documentation manual should be extended in nursing care practices to increase the quality of nursing documentation. That would reflect effective nursing care for patients.

Keywords: nursing documentation, nursing documentation audit, professional nurses

DOI: 10.20472/IAC.2015.015.151

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