Evaluation of nursing documentation: The experience of nurses from the primary and secondary/tertiary health care

Šeila Cilović-Lagarija,Jasmina Mahmutović,Ekrem Mrakić,Senada Mujačić,Nino Hasanica,Dragana Galić,Salih Slijepčević,Selma Čajdrić,Suada Branković,Elvedin Dervišević,Kristina Perić,Sanela Tukulija

doi:10.17532/jhsci.2020.1086

Abstract

Introduction: Aim of the study is to piloting nursing documentation to obtain comments based on the experience of nurses/medical technicians from the primary, secondary, and tertiary health care about the documentation before it is published and starts being used.Methods: A questionnaire was designed in the electronic form to be used for the evaluation and suggestions by nurses/medical technicians on the piloted form and content of nursing documentation for all levels of health care. A piloting sample was prepared to make 10% of nurses/medical technicians from health care institutions from the territory of the Federation of Bosnia and Herzegovina.Results: A total of 94.3% of examinees at the primary health care level and only 17.2% of the examinees in the secondary and tertiary health care fill out nursing documentation both manually and electronically. All examinees at all levels of health care understand the purpose and importance of nursing documentation. A total of 27.7% of the examinees at the primary and 40.9% of the examinees at the secondary and tertiary level of health care pointed out that filling out nursing documentation was too time-consuming.Conclusion: A total of 51.2% of the examinees at the primary and 64.2% at the secondary and tertiary level of health care agreed that submitted nursing documentation was adequate for use. It is suggested that after the adoption of nursing documentation at all levels of health care, piloting of its use should be conducted to evaluate the quality and quantity of all nursing documentation.

Highlights

Aim of the study is to piloting nursing documentation to obtain comments based on the experience of nurses/medical technicians from the primary, secondary, and tertiary health care about the documentation before it is published and starts being used
Of the total number of the examinees at the primary health care level, 65 (94.3%) examinees filled out the nursing documentation both manually and electronically, which is an indicator of a high workload of nurses/medical technicians, having in mind that their primary role is to care for patients (Table 2 and Graph 1)
Half of the examinees emphasized that the greatest advantage of the nursing documentation was improved quality of health care and health protection, while 24 (34.1%) examinees believed that it was the safety of nurses/medical technicians in potential court proceedings (Table 3 and Graph 2)

Summary

Introduction

Aim of the study is to piloting nursing documentation to obtain comments based on the experience of nurses/medical technicians from the primary, secondary, and tertiary health care about the documentation before it is published and starts being used. Skills and authority of nurses with higher education, inter alia, include making and keeping records related to health care and their responsibility for advancing health care and organization of the health care system [3]. In their everyday work, nurses, just like other medical professionals, use various forms of expression, from layman’s terms while speaking with a patient and his/her family to highly expert terminology while talking to colleagues or writing nursing documentation [4,5]. It is possible to define nursing tasks and responsibilities more clearly and estimate both the quantity and quality of the performed work [6,7]

Methods

Results

Discussion

Conclusion