Department of Medical Surgical Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran.
J Multidiscip Healthc. 2013 Dec 2;6:441-50. doi: 10.2147/JMDH.S53252. eCollection 2013.
The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation.
A quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist.
There were no differences between a nurse's demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program.
Although some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.
护理文件记录的质量在护理行业乃至整个医疗保健行业仍然是一个挑战。临床治理是提高护理文件记录质量的主要质量改进计划之一，其使命是不断提高患者护理质量并解决服务质量问题。本研究旨在确定临床治理是否能提高护理文件记录的质量。
采用准实验方法，展示临床治理实施 2 年后护理文件记录质量的提高。使用经过验证和可靠的研究者自制清单，对 220 份随机护理文件进行结构和内容评估。
在临床治理实施 2 年后，护士的人口统计学数据前后没有差异（P>0.05），且护理文件记录评分也没有提高。
尽管通过临床治理做出了一些改进护理文件记录的努力，但这些努力还不够，需要更多的尝试。
