Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran

  • Seyed Majid Vafaei PhD Candidate in Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad
  • Zahra Sadat Manzari Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad
  • Abbas Heydari Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad
  • Razieh Froutan Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad
  • Leila Amiri Farahani Department of Reproductive Health and Midwifery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran
Keywords: Documentation, Health Services Research, Action Research, Nursing, Emergency Service, Hospital

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.

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Published
2018-08-19
How to Cite
1.
Vafaei SM, Manzari ZS, Heydari A, Froutan R, Amiri Farahani L. Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran. Open Access Maced J Med Sci [Internet]. 2018Aug.19 [cited 2020Nov.29];6(8):1527-32. Available from: https://www.id-press.eu/mjms/article/view/oamjms.2018.303
Section
E - Public Health