Nurses' Performance toward Quality Documentation for Patients in ICU: Suggested Guidelines

Document Type : Original Article

Authors

1 Medical Surgical Nursing Faculty of Nursing - Ain Shams University.

2 B.Sc. In Nursing - Faculty of Nursing - Ain Shams University.

Abstract

Background: Nursing documentation is the recording, documenting or charting of
nursing care that is planned or given to the patients in intensive care unit (ICU) by qualified
nurses. It is any written or electronically generated information about a client that describes the
care or service provided to that client. The aims of this study were: 1. Assessing nurses'
performance toward quality documentation for patients in ICU. 2. Suggesting guidelines for
quality documentation for patients in ICU. Study design: a descriptive study was used to
achieve the aim of this study Subject: A convenient sample includes all registered nurses (50).
Setting: This study was conducted in intensive care unit affiliated to Mansoura Emergency
Hospital Tools: three tools were used for data collection; self-administered questionnaire,
nurses’ practice observational checklist and nurses' attitude likert scale. Results and
conclusion the results of this study showed that, more than half of the studied nurses had got
satisfactory level of knowledge, near three quarter of studied sample had got unsatisfactory
level of practice, and more than three fifth had got negative attitude toward quality
documentation for patients in ICU. Recommendation Training program including the
suggested guidelines toward quality documentation for patients in ICU must be implemented
for nurses based on their need assessment, and evaluate its effectiveness on their performance.

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