تدوين و اجراي برنامه هدايتي بر كيفيت ثبت گزارش هاي پرستاري بخش سي .سي .يو

Planning and Implementing the Directional Program for the Quality of the Nursing Notes in C.C.U Documentation of Shahid Mostafa Khomeini Hospital

Introduction: This semi-experimental study with before - after format of intervention was conducted to evaluate the effect of performing directional program on documentation quality of nursing notes in CCU of Mostafa Khomaini Hospital in 1381 (2003). Material and Method: The subjects consisted of all CCU nurses. Also, the patientʹs records were randomly selected without replacement. Data gathering tools included a questionnaire for determining nursesʹ attitudes toward their notes and a checklist for documentation quality of these notes. Before intervention, documentation quality and nurseʹs attitudes were assessed by evaluating 52 notes and the questionnaires. Directional program consisted of 5 stages: 1) Holding 2-3 individual sessions for providing or enhancing positive attitudes toward nursing notes, ways of correct documentation, and discussing about functional and case methods; 2) Providing nurses with educational pamphlets about documentation and common conditions in CCU, a checklist regarding documentation, CCU cardex, and books such as "pharmacological guides... in nursing station", 3) Changing task division from functional to case method; 4) Practicing correct documentation with nurses; and 5) performing directional program by personnel and changing the responsibility of controlling and checking nursing notes from head nurse to charge nurses of each shift. 1-5-2 months after the program, data regarding documentation quality and nursesʹ attitudes were gathered again. Results: Findings showed no significant difference between nursesʹ attitudes before and after intervention with McNimar test (p<0.62). Thus, the first hypothesis of the study, namely, "the effect of directional program on improving attitudes toward nursing notes" was not verified. In addition, there was a significant difference between documentation quality with Qul-Square test (p<0.01) and between mean scores of documentation with paired T-test before and after intervention. Therefore, the second hypothesis of the study, i.e., "The effect of directional program on changing documentation quality of nursing notes" was verified. There was also a significant relation between nursesʹ attitudes and documentation quality after intervention. A significant was also found relation between sex, nursing experience, and documentation quality. The effectiveness of the program was 81.75. Conclusion: It can be concluded that nursing managers can use appropriate directional program to make desired changes in clinical practice.