Mutshatshi Takalani E, Mothiba Tebogo M, Mamogobo Pamela M, Mbombi Masenyani O
Department of Nursing Science, University of Limpopo.
Curationis. 2018 Jul 30;41(1):e1-e6. doi: 10.4102/curationis.v41i1.1931.
Patients' records provide a trace of care processes that have occurred and are further used as communication amongst nurses for continued management of patients. Nurses have the responsibility to ensure that records are accurate and complete in order to effectively manage their patients. In hospitals, nurses have to record a wide range of information in the patient's records and this leads to increased workload on the part of nurses that compromises accurate record-keeping.
The purpose of this study was to explore and describe the challenges experienced by nurses with regard to record-keeping at selected public hospitals in the Vhembe district, Limpopo Province, South Africa.
A qualitative, explorative and descriptive research design was used. Nurses working in selected public hospitals were purposively selected and semi-structured interviews were conducted until data saturation was reached. Data were analysed using the Tesch's open-coding method.
Nurses working in public hospitals experience record-keeping as a challenging activity owing to a variety of challenges which include lack of time to complete the records, increased patients' admission and shortage of recording material.
Record-keeping is not done properly which is problematic, and it is recommended that there should be continuous training, monitoring and evaluation of nurses on record-keeping issues, supply of adequate recording materials and proper time management amongst nurses to improve record-keeping challenges. The need for comprehensive record-keeping remains fundamental in public hospitals in order to improve patient care.
患者记录提供了已发生的护理过程的踪迹，并进一步用作护士之间沟通以持续管理患者的工具。护士有责任确保记录准确完整，以便有效地管理患者。在医院中，护士必须在患者记录中记录大量信息，这增加了护士的工作量，从而影响了准确的记录保存。
本研究的目的是探索和描述南非林波波省韦姆贝区选定公立医院的护士在记录保存方面所面临的挑战。
采用定性、探索性和描述性研究设计。有目的地选择在选定公立医院工作的护士，并进行半结构化访谈，直至达到数据饱和。使用泰施的开放编码方法对数据进行分析。
由于各种挑战，包括缺乏完成记录的时间、患者入院人数增加以及记录材料短缺，在公立医院工作的护士将记录保存视为一项具有挑战性的活动。
记录保存做得不当，这是个问题，建议应持续对护士进行记录保存问题的培训、监测和评估，提供充足的记录材料，并在护士中进行适当的时间管理，以改善记录保存方面的挑战。为了改善患者护理，公立医院全面记录保存的需求仍然至关重要。
