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IJNR 2017, 12(2): 38-44 Back to browse issues page
A Review of Quality of Nursing Documentation in Different Fields and the Lack of Proper Reporting by Nurses in Shahid Beheshti Hospital in Yasouj
soheila zabolypour, sepideh mohammadi , mohammad fararooei, marzieh hosseini, maryam bazgirian
phd candidate University of Medical Sciences, Isfahan, Iran , sepid.mohamadi@nm.mui.ac.ir
Abstract:   (1106 Views)

Introduction: Nursing documentation is one of the most important responsibilities in nursing, yet after decades of education and importance of correct nursing documentation, many problems still remain. This study was done with an aim to check the quality of nursing documentation in different areas and reasons for lack of proper nursing reports at Yasuj Shahid Beheshti hospital.

Methods: This was a cross-sectional study conducted during year 2013. Samples were 120 records of admitted patients and 100 nurses, who were randomly selected. Research tools included the check-list of common reports, admission, discharge, and pre-postoperative records. Other check-lists were reasons of incorrect nursing documentation. Data were analyzed with the SPSS 16 software.

Results: Percentage of correct records was 56% on admission, 82% at discharge, 44% before surgery, and 68% after surgery. The nurses' lack of time, high workload, and fatigue were the most important reasons for correct documentation.

Conclusions: The results of this study therefore provide an opportunity for nurses and administrators to pay more attention to items with weak documentation, and help promote nursing reports. Nurses' workload and fatigue must be reduced, leading to a lack of accurate documentation.

Keywords: Nursing Reporting, Nursing Documentation, Quality of Nursing Documentation
Full-Text [PDF 302 kb]   (262 Downloads)    
Type of Study: Nursing Management and Administration | Subject: nursing
Received: 2016/10/15 | Accepted: 2016/12/22 | Published: 2017/05/21
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zabolypour S, mohammadi S, fararooei M, hosseini M, bazgirian M. A Review of Quality of Nursing Documentation in Different Fields and the Lack of Proper Reporting by Nurses in Shahid Beheshti Hospital in Yasouj. IJNR. 2017; 12 (2) :38-44
URL: http://ijnr.ir/article-1-1814-en.html
Volume 12, Number 2 (May-June 2017) Back to browse issues page
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