Evaluating the quality of nursing documentation in pediatric wards of Motahari Hospital of Urmia in 2017

Abstract

Introduction: Nursing documentation is one of the main functions of the nurses and it involves recording of measures taken for patients. Observing the proper principles protects the life of patients and nurses. The current research was carried out to evaluate the quality of nursing documentation in pediatric wards. Methodology: In this descriptive research, the quality of nursing documentation in pediatric wards was evaluated. Demographic questionnaire and a checklist to evaluate the nursing documentation quality were used to collect data. The checklist validity was examined by obtaining the views of 10 nursing professors. The level of agreement of observers was used to determine its reliability. Accordingly, 10 primary medical records were examined and scored by two people and the level of agreement between the observers by using Cohen's kappa coefficient was obtained to be 0.7, which is an acceptable value. The checklist used to evaluate the quality of the nursing documentation included four options. The sample size was 175 nurses, of which three documentations of each nurse were evaluated. The documentations related to each nurse selected randomly among the existing medical records. Descriptive and inferential statistics were used to analyze the data. Findings: The employed nurses had mean age of 28.48 +/- 5.57 years, they had mean working experience of 5.09 +/- 4.86 years, and they cared for 9.55 +/- 3.06 patients on average. In total, 95.4% of the documentations were related to morning shift, 83.4% of them were related to evening shift, and 94.9% of them were related to night shift. The findings revealed that the quality of the documentation was reduced significantly by increasing age (r = -0.28, r = 0.000) and working experience of the nurses (r = -0.27 and p = 0.000). Discussion and conclusion: The findings revealed that the quality of nursing documentation in internal surgical pediatric wards had desirable quality and the quality of the documentation was reduced by increasing age and work experience.