The Relationship between Quality of Nursing Documentation System and Continuity of Patient Care in Medicine Hospital at Cairo University Hospital
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- Category: Vol. 82, September 2014
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The Relationship between Quality of Nursing Documentation System and Continuity of Patient Care in Medicine Hospital at Cairo University Hospital, EGLAL ABDEL-WAHAB and BASHAIR M. ELSAYED
Abstract
Nursing documentation is an integral part of clinical documentation and is fundamental nursing responsibility. Good documentation ensures continuity of care furnishes legal evidence of the process of care and supports evaluation of patient care.
Aim: To assess the relationship between quality of nursing documentation system and the continuity of patient care in Medicine Hospital.
Subject and Methods: The first sample was a convenient sample of (44) unit managers and staff nurses working at six floors for in patients services in medicine hospital. The second sample was auditing of (540) of total records of each floor all over a three month period during 2013. For the purpose of this study, one quality of nursing documentation system questionnaire, second tool auditing checklist about quality of nursing documentation was modified and utilized and third tool was developed and used about continuity of care.
Results: The current study showed that there was a highly statistical significant positive correlation between total ob-served quality of nursing documentation and total observed continuity of patient care.
Conclusions: All nurses of Medicine Hospital agreed about importance of quality of nursing documentation and continuity of patient care, there was unsatisfactory level of quality of nursing documentation and there was unsatisfactory level of continuity of patient care. There was a highly statistical significant positive correlation between quality of nursing documentation and continuity of patient care.
Recommendations: In-service training program for nurses included skills for haw to document; how to use nursing documentation formats and importance of nursing documen-tation and how to record and used for continuity of patient care and continuous staff development activities to update nurses’ skills and providing guidance related to documentation, establishment of nursing audit committee for reviewing and revising of hospital documentation forms and unit managers should increase their review, round, follow-up and updating knowledge, skills and forms used to improve quality of nurses’ documentation. Documentation forms should be simple and include only necessary data, to save the time and decrease workload on nurses. Motivation for nurses about quality of nursing documentation. Hospital decision makers create strategies to decrease workload on nurses.