Lindo Jascinth, Stennett Rosain, Stephenson-Wilson Kayon, Barrett Kerry Ann, Bunnaman Donna, Anderson-Johnson Pauline, Waugh-Brown Veronica, Wint Yvonne
Lecturer, The University of the West Indies School of Nursing, Mona Kingston, Jamacia and Barry University, Miami, FL, USA.
Research Assistant, The University of the West Indies School of Nursing, Mona, Kingston, Jamaica.
J Nurs Scholarsh. 2016 Sep;48(5):499-507. doi: 10.1111/jnu.12234. Epub 2016 Jul 26.
Nursing documentation provides an important indicator of the quality of care provided for hospitalized patients. This study assessed the quality of nursing documentation on medical wards at three hospitals in Jamaica.
This cross-sectional study audited a multilevel stratified sample of 245 patient records from three type B hospitals. An audit instrument which assessed nursing documentation of client history, biological data, client assessment, nursing standards, discharge planning, and teaching facilitated data collection. Descriptive statistics were conducted using IBM SPSS, Version 19 (IBM Inc., Armonk, NY, USA).
Records from three hospitals (Hospital 1, n = 119, 48.6%; Hospital 2, n = 56, 22.9%; Hospital 3, n = 70, 28.6%) were audited. Documented evidence of the patient's chief complaint (81.6%), history of present illness (78.8%), past health (79.2%), and family health (11.0%) were noted; however, less than a third of the dockets audited recorded adequate assessment data (e.g., occupation or living accommodations of patients). The audit noted 90% of records had a physical assessment completed within 24 hr of admission and entries timed, dated, and signed by a nurse. Less than 5% of dockets had evidence of patient teaching, and 13.5% had documented evidence of discharge planning conducted within 72 hr of admission.
This study highlights the weakness in nursing documentation and the need for increased training and continued monitoring of nursing documentation at the hospitals studied. Additional research regarding the factors that affect nursing documentation practice could prove useful.
The study provides valuable information for the development of strategic risk management programs geared at improving the quality of care delivered to clients and presents an opportunity for nurse leaders to implement structured interventions geared at improving nursing documentation in Jamaica. In light of Jamaica's epidemiologic transition of chronic diseases, gaps in nurses' documentation of client assessment, patient teaching, and discharge planning should be addressed with urgency. Patient teaching and discharge planning enable the clients to participate more effectively in their health maintenance process.
护理记录是衡量为住院患者提供的护理质量的一项重要指标。本研究评估了牙买加三家医院内科病房护理记录的质量。
这项横断面研究对来自三家乙类医院的245份患者记录进行了多级分层抽样审核。一份审核工具用于评估患者病史、生物数据、患者评估、护理标准、出院计划及宣教方面的护理记录，以促进数据收集。使用IBM SPSS 19版软件（美国纽约州阿蒙克市IBM公司）进行描述性统计分析。
对三家医院的记录进行了审核（医院1，n = 119，48.6%；医院2，n = 56，22.9%；医院3，n = 70，28.6%）。记录了患者主诉（81.6%）、现病史（78.8%）、既往健康状况（79.2%）及家族健康状况（11.0%）的相关证据；然而，审核的病历中不足三分之一记录了充分的评估数据（如患者的职业或居住情况）。审核发现90%的记录在入院24小时内完成了体格检查，且记录有护士标注的时间、日期并签名。不足5%的病历有患者宣教的证据，13.5%的病历有在入院72小时内进行出院计划的记录证据。
本研究凸显了护理记录方面的薄弱环节，以及在所研究的医院中加强护理记录培训和持续监测的必要性。关于影响护理记录实践的因素的更多研究可能会有所帮助。
该研究为制定旨在提高为患者提供的护理质量的战略风险管理计划提供了有价值的信息，并为牙买加的护理领导者提供了一个实施结构化干预措施以改善护理记录的机会。鉴于牙买加慢性病的流行病学转变，护士在患者评估、患者宣教及出院计划记录方面的差距应亟待解决。患者宣教和出院计划能使患者更有效地参与自身的健康维护过程。
