Improving nursing care documentation in emergency department: A participatory action research study in iran

Vafaei, S. M. and Manzari, Z. S. and Heydari, A. and Froutan, R. and Farahani, L. A. (2018) Improving nursing care documentation in emergency department: A participatory action research study in iran. Open Access Macedonian Journal of Medical Sciences, 6 (8). pp. 1527-1532.

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Abstract

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. © 2018 Seyed Majid Vafaei, Zahra Sadat Manzari, Abbas Heydari, Razieh Froutan, Leila Amiri Farahani. This is an open-access article distributed under.

Item Type: Article
Additional Information: Export Date: 16 February 2020 Correspondence Address: Manzari, Z.S.; School of Nursing and Midwifery, Mashhad University of Medical SciencesIran; email: Manzariz@mums.ac.ir
Uncontrolled Keywords: Action research Documentation Emergency service Health services research Hospital Nursing accreditation adult article emergency health service emergency ward employee hospital information system human Iran leadership medical education monitoring patient education protocol compliance punishment quality of nursing care reward
Subjects: WB Practice of Medicine
WY Nursing
Divisions: Mashhad University of Medical Sciences
Depositing User: lib2 lib2 lib2
Date Deposited: 27 Apr 2020 05:58
Last Modified: 27 Apr 2020 05:58
URI: http://eprints.mums.ac.ir/id/eprint/17568

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