Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran
DOI:
https://doi.org/10.3889/oamjms.2018.303Keywords:
Documentation, Health Services Research, Action Research, Nursing, Emergency Service, HospitalAbstract
BACKGROUND: Standardization of documentation has enabled the use of medical records as a primary tool for evaluating health care functions and obtaining appropriate credit points for medical centres. However, previous studies have shown that the quality of medical records in emergency departments is unsatisfactory.
AIM: The aim of this study was improving the nursing care documentation in an emergency department, in Iran.
MATERIAL AND METHODS: This collaborative action research study was carried out in two phases to improve nursing care documentation in cooperation with individuals involved in the process, from February 2015 to December 2017 in an affiliated academic hospital in Iran. The first phase featured virtual training, an educational workshop, and improvements to the hospital information system. The second phase involved the recruitment of human resources, the implementation of continuous codified training, the establishment of an appropriate reward and penalty system, and the review of patient education forms.
RESULTS: The interventions improved nursing documentation quality score of 73.20%, which was the highest accreditation ranking provided by Iran’s Ministry of Health and Medical Education in 2017. In other words, this study caused a 32% improvement in the quality of nursing care documentation in the hospital.
CONCLUSION: The appropriate practices for improving nursing care documentation are employee participation, managerial accountability, nurses’ adherence to documentation standards, improved leadership style, and continuous monitoring and control.Downloads
Metrics
Plum Analytics Artifact Widget Block
References
Papathanasiou I, Kotrotsiou S, Bletsa V. Nursing documentation and recording systems of nursing care. Health Sci J. 2007; 1(4).
Nakate GM, Dahl D, Petrucka P, Drake KB, Dunlap R. The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital. Open Journal of Nursing. 2015; 5(12):1063-1071. https://doi.org/10.4236/ojn.2015.512113
Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract. 2010; 16(2):112-24. https://doi.org/10.1111/j.1440-172X.2009.01815.x PMid:20487056
Karimi Moonaghi H, Emami Zeydi A, Mirhaghi A. Patient education among nurses: bringing evidence into clinical applicability in Iran. Invest Educ Enferm. 2016;34(1):137-151. https://doi.org/10.17533/udea.iee.v34n1a16 PMid: 28569983
Daly P. Clinical nurses lead the charge with EHR. Nursing. 2015; 45(10):25-6. https://doi.org/10.1097/01.NURSE.0000471426.47075.d2 PMid:26372237
Farhan J A-JS, Alrajhi AA, Al-Rayes H, Al-Nasser A. Documentation and coding of medical records in a tertiary care center: a pilot study. Ann Saudi Med. 2005; 25(1):46-9. https://doi.org/10.5144/0256-4947.2005.46
Phillips ASK, Williams M. Medical record documentation: the quality of physiotherapy entries. J Allied Health. 2006; 4(3):1-17.
Abadi AM. Medical assistants and students' knowledge and practice rate of Semnan Medical Sciences University regarding documentation of cares provided to patient from medicolegal aspect. IJFM. 2007; 13(2):92-7.
O'brien A, Weaver C, Hook ML, Ivory CH. EHR documentation: the hype and the hope for improving nursing satisfaction and quality outcomes. Nursing administration quarterly. 2015; 39(4):333-9. https://doi.org/10.1097/NAQ.0000000000000132 PMid:26340245
Valdez-Delgado K, Barba M, Kulyen A, Colston P, Boyer S, Mann-Salinas E. Evolution Of An Evidence-based Competency Assessment Program For Specialty Nursing. J Crit Care Med. 2018; 46(1):485. https://doi.org/10.1097/01.ccm.0000529009.61144.72
Mohammadi Firouzeh M, Jafarjalal E, Emamzadeh Ghasemi HS, Bahrani N, Sardashti S. Evaluation of vocal-electronic nursing documentation: A comparison study in Iran. Inform Health Soc Care. 2017; 42(3):250-260. https://doi.org/10.1080/17538157.2016.1178119 PMid:27322956
Saravi BM, Asgari Z, Siamian H, Farahabadi EB, Gorji AH, Motamed N, et al. Documentation of Medical Records in Hospitals of Mazandaran University of Medical Sciences in 2014: a Quantitative Study. Acta Informatica Medica. 2016; 24(3):202-6. https://doi.org/10.5455/aim.2016.24.202-206 PMid:27482136 PMCid:PMC4949052
Vafaei SM Manzari ZS, Heydari A,Froutan R, Amiri Farahani L. Nurses perception of nursing services documentation barriers: a qualitative approach. Electron J Gen Med. 2018; 12(2):45-56.
Blair W, Smith B. Nursing documentation: Frameworks and barriers. Contemp Nurse. 2012; 41(2):160-8. https://doi.org/10.5172/conu.2012.41.2.160 PMid:22800381
Cordeiro L, Rittenmeyer L, Soares CB. Action research methodology in the health care field: a scoping review protocol. JBI Database System Rev Implement Rep. 2015; 13(8):70-8.
Okaisu EMK, F.Wanyana, G.Coetzee, M. Improving the quality of nursing documentation: An action research project. Curationis. 2014; 37(2): E1-11. https://doi.org/10.4102/curationis.v37i2.1251 PMid:26864179
Corben V. The Buckinghamshire nursing record audit tool: a unique approach to documentation. Journal of Nursing Management. 1997; 5(5):289-93. https://doi.org/10.1046/j.1365-2834.1997.00024.x PMid:9348843
Vabo G, Slettebo A, Fossum M. Nursing Documentation: An Evaluation of an Action Research Project. Stud Health Technol Inform. 2016; 225:842-3. PMid:27332370
Dehghan MD, Dorsa Sheikhrabori, AkbarSadeghi, Masoume Jalalian, Mehrdad. Quality improvement in clinical documentation: does clinical governance work? Journal of multidisciplinary healthcare. 2013; 6:441-50. https://doi.org/10.2147/JMDH.S53252 PMid:24324339 PMCid:PMC3855011
Darmer MR AL, Nielsen BG, Landberger G, Lippert E, Egerod I. The effect of a VIPS implementation program on nurses' knowledge and attitudes towards documentation. Scand J Caring Sci. 2004; 18(3):325-32. https://doi.org/10.1111/j.1471-6712.2004.00289.x PMid:15355528
Ofi BaS, O. Nursing Documentation: Experience of the Use of the Nursing Process Model in Selected Hospitals in Ibadan, Oyo State, Nigeria. Int J Nurs Pract. 2012; 18(4):354-62. https://doi.org/10.1111/j.1440-172X.2012.02044.x PMid:22845635
Keenan G, Yakel E, Dunn Lopez K, Tschannen D, Ford YB. Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. J Am Med Inform Assoc. 2013; 20(2):245-51. https://doi.org/10.1136/amiajnl-2012-000894
PMid:22822042 PMCid:PMC3638178
Esmailian M N-EM, Sajad Brahimi A. The Quality of Patients' Files Documentation in Emergency Department; a Cross Sectional Study. Iranian Journal of Emergency Medicine. 2014; 1(1):16-21.
Downloads
Published
How to Cite
Issue
Section
License
http://creativecommons.org/licenses/by-nc/4.0