Learning Objective 1: The learner will be able to understand the process in developing a home care record.
Learning Objective 2: The learner will be able to determine variables needed to monitor quality of home care.
Design: Ongoing action research (Phase 1)
Population, Sample, Setting, Years: The sample of 12 home care nurses volunteered to participate in the focus groups and 61 records were randomized from home care files at Ramathibodi Hospital, Thailand during 2003-2005.
Conceptual framework applied was the Andersen Model which included patients' and families' factors, home care provision and outcomes.
Methods: Three focus groups of home care nurses discussed and summarized the data needed for care improvement. The evidence-based studies were review to determined variables related to home care provision and outcomes. The home care nurses were explained and clarified about the new record. After several trials to test for feasibility and the understanding of home care nurses, several changes were made during the first and second year of the project. In 2005, an auditor-team was set up and the total record of 61were reviewed and audited.
Findings: The results showed that only 1-3% of the categories of family and caregiver profile, home environment and outcomes were below average. The completeness of assessment of the patient and family was 29.5% and 32.8%. Correctly determined nursing diagnosis and supporting data, nursing intervention and outcomes were 27.9%, 31.1% and 24.6%, respectively.
Conclusions: The home care nurses have satisfied with the new record that is more convenience but the completeness of the data especially the subjective data still needs improvement.
Implication: To complete the record, individual supervision and a continuing education of nursing process will help nurses understand the data needed for documentation.