| Learning Objective #1: Understand the development process of an effective nursing-recording system | |||
| Learning Objective #2: Understand and apply this effective nursing-recording system to one's own work |
Practice problem: The recording problems involved recording itself and nursing practice including irrelevant to nursing process, unfit forms, repetition, incomplete and different styles charting, and irregular documenting. The practice showed nurses’ incompetence in recording and practice, and insufficient monitoring and counseling.
Learner objective: To develop an effective nursing recording system based on data gathered from a hospital in Thailand.
Design: A case study which adopted an action research methodology.
Sample, setting, years: The number of nurses ranged from 10-15 persons working at a medical-surgical unit of Saint Louis Hospital in Thailand were participants of this study between December 1999 to January 2001.
Methods: The preparation was undertaken establishing good relationship with the nurses; and informing the research objectives, participants’ roles, and the researcher’s roles. Then, three stages were carried out respectively. Stage 1 was studying of the context. Stage 2 involved developing a preliminary nursing recording system and pre-testing to provide the basis for comparison with two post-testings. Stage 3 was refining the new system four cycles until achieving the effective system. Two post-tesings were undertaken at the middle of the fourth cycle of stage 3 and after post-testing 1 respectively to confirm the sustainability of using the recording system.
Findings: An effective nursing recording system was achieved through empowering the nurses to participate in the research. This system included contents of health problems, nursing care, and patient outcomes that were factual, current, complete, and concise. The forms including charting guidelines facilitated charting and retrieval. Recording procedures involved nursing process and discharge planning; and using the recording manual, the nurse-patient chart, and the medication and treatment chart.
Its outcomes which included the completeness of the recording system, the patient’s satisfaction with the quality of care, and the nurses’ perceived value of the recording system were higher than the traditional system.
Back to Innovations for Improving Clinical Health Systems
Back to 37th Biennial Convention - Clinical Sessions
Sigma Theta Tau International