Predicting the related factors with the quality of nursing documentation of patients with poisoning diagnosis in the emergency department of Sina Hospital in Tabriz in 2021-2022

Abstract

Abstract Predicting the related factors with the quality of nursing documentation of patients with poisoning diagnosis in the emergency department of Sina Hospital in Tabriz in 2021-2022 Background and aim: The quality of nursing documentation reflects the quality of care provided to the client, it is very important to measure the factors affecting it, especially in the poisoning case in the emergency department. Therefore, the purpose of this research was to determine the related factors with the quality of nursing documentation of patients with poisoning diagnosis in the emergency department of Sina Hospital in Tabriz in 2021-2022. Method: The current study is a correlation study. Sampling of medical records of the last six months of 2022 in the medical records archive was done with simple random method. Variables related to the patient and the quality of nursing reports were recorded based on the checklist from files. Also, the knowledge and attitude of nurses towards nursing documentation and management factors related to it were completed by 35 emergency nurses who were included in the study by census. SPSS version 21 and descriptive and analytical tests were used for data analysis. A statistical significance level of less than 0.05 was considered. Findings: Most of the patients whose files were reviewed (64.3%) were between 21-40 years old and diagnosed with drug poisoning (61.7%). The net score of report was -0.06 and of drug was +0.68. The quality of documentation was statistically significant in terms of patient's age (P=0.014), patient's education (P=0.023), history of alcohol consumption in the patient (P<0.001), and history of admission to the emergency room (P=0.021). The mean and standard deviation of nurses' knowledge, attitude and management factors were 10.37 ± 2.30, 92.08 ± 8.25, and 41.11 ± 10.45, respectively. Nurses' knowledge according to shift type (P=0.002), attitude according to marital status (P=0.001) and management factors with nurses' attitude, had a significant relationship. Conclusion: According to the findings, the quality of the nursing documents was average. The quality of report writing was poor and the quality of medicine record was good. Most of the nurses had average knowledge and had a positive attitude towards documentation. Also, in the present study, the average effect of management factors was obtained. Based on the identified effective factors, it is necessary to take appropriate measures such as strengthening student education and in-service training in order to improve the conditions.