Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran

Abstract

BACKGROUND:Standardization of documentation has enabled the use of medical records as a primary tool for evaluating health care functions and obtaining appropriate credit points for medical centres. However, previous studies have shown that the quality of medical records in emergency departments is unsatisfactory.AIM:The aim of this study was improving the nursing care documentation in an emergency department, in Iran.MATERIAL AND METHODS:This collaborative action research study was carried out in two phases to improve nursing care documentation in cooperation with individuals involved in the process, from February 2015 to December 2017 in an affiliated academic hospital in Iran. The first phase featured virtual training, an educational workshop, and improvements to the hospital information system. The second phase involved the recruitment of human resources, the implementation of continuous codified training, the establishment of an appropriate reward and penalty system, and the review of patient education forms.RESULTS:The interventions improved nursing documentation quality score of 73.20%, which was the highest accreditation ranking provided by Iran’s Ministry of Health and Medical Education in 2017. In other words, this study caused a 32% improvement in the quality of nursing care documentation in the hospital.CONCLUSION:The appropriate practices for improving nursing care documentation are employee participation, managerial accountability, nurses’ adherence to documentation standards, improved leadership style, and continuous monitoring and control.

Nursing diagnosis identification by nurses in burn wards: A descriptive cross‐sectional study

“…Studies on nursing documentation in Iran have focused more on the quality of nursing documentation. These studies have reported the quality of nursing documentation was unsuitable and did not contain necessary information (Tabrizi et al, 2016; Vafaei, Manzari, Heydari, Froutan, & Farahani, 2018). These studies reviewed the nursing records of patients based on nursing activities though they did not pay attention to patient care needs and the documented nursing diagnoses.…”

Situation of labour room documentation at secondary level public health facilities of Cuttack district, Odisha, India – A SWOT analysis

“…These weaknesses have similarly been highlighted in many other studies. [ 21 22 23 24 25 26 27 ] Studies have identified factors such as time constraint, attitude of the midwives, availability of few numbers of midwives in a shift[ 5 6 ], and no emphasis from the administrators[ 19 ] to influence the incomplete LR documentation. A qualitative study on maternity care in secondary level public health facilities of Uttar Pradesh, has highlighted the availability of infrastructure, human resources, supplies, and medicines as critical for quality improvement in service delivery.…”

“…[ 5 ] It helps in qualitative assessment of records during medical jurisprudence, death audits, and case review. [ 6 7 ] Availability and maintenance of a good documentation system is also critical for facility level review of records. [ 8 ] However, there exist gaps towards adherence and completeness in LR documentation.…”

<b>O potencial da mudança organizacional planejada na produção do conhecimento em enfermagem e saúde / Potential of planned organizational change in the production of knowledge in nursing and health<b>

“…Embora a MOP se baseie em um dos modelos mais antigos de gestão da mudança, ela se aplica ao contexto contemporâneo e consiste em alicerce para os processos de mudança no contexto da saúde e da enfermagem, sendo atual para os dias de hoje (3,(13)(14)(15)(16)(17)(18)(19)(20) .…”

“…No que diz respeito a esses estudos, destacamos alguns que apontam resultados positivos na gestão de mudanças. Estudo realizado no Irã (20) demonstrou práticas mais apropriadas para melhorar a documentação dos cuidados de enfermagem. Na perspectiva dos autores, a participação dos profissionais, a responsabilidade gerencial, a adesão dos enfermeiros aos padrões de documentação, a melhoria do estilo de liderança e o monitoramento e controle contínuos foram importantes ganhos da investigação.…”