Abstract
Retrospective Study to Audit Nursing Documentation of Psychiatric Patients of Selected Hospital, Ludhiana, Punjab. The purpose of this study was to evaluate the nursing documentation through auditing with a view to prepare nursing documentation protocol. Objectives of the study were to audit nursing documentation of psychiatric patients’ bed side charts, to ascertain nursing documentation in relation to the variables like: duration of hospitalization, years of nursing documentation records and to prepare nursing documentation protocol. The present study was conducted to audit nursing documentation of psychiatric patients’ bed side charts. The area selected for the study was medical record office of Christian Medical College & Hospital, Ludhiana, Punjab. Retrospective approach was used in the study. Sample was selected using random sampling technique, time spent to audit each psychiatric patients’ bed side charts was of 15–20 min. Structured nursing documentation audit tool was used to collect required data. Reliability was 0.79. Try-out was conducted on four psychiatric patients’ bed side charts to find out the wording and clarity of the research tool. Pilot study was conducted on 20 psychiatric patients’ bed side charts to check the feasibility and practicability of the study. Final study was carried out on 200 psychiatric patients’ bed side charts in the month of December,2010-January,2011. Descriptive and inferential statistics were employed to analyse the data. Bar diagrams and pie charts were used to depict the findings. On the basis of mean score most deficit area of nursing documentation was treatment sheet and least deficit area was vital signs chart of psychiatric patients. Relationship of nursing documentation with duration of hospitalization and year of nursing documentation were not found statistically significant. Findings revealed that nursing documentation of psychiatric patients’ bed side charts need improvement and protocol for nursing documentation need to be administered.
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