Abstract
Background: A patient medical record ( chart ) is a legal document which may be used in court as evidence, so it is important that every chart and record must have clear, simple and an accurate language.Objective of study: The study aims to evaluating of nursing staffs documentation standard in medical and, finding out the association between nursing staffs documentation and sociodemographic characteristic of (age, gender, education level , and years of experience).Methodology: A descriptive study was carried out to evaluation of nursing staffs' documentation standard related to nursing procedures in medical wards. A purposive sample of (71) nurses was selected from medical wards of hospitals (Al-Sadder Medical City, Al-Manathra General Hospital, Al-Forat General Hospital, Al-Haydaria General Hospital, Al-Sagaad General Hospital and Al-Hakeem General Hospital) in Al Najaf governorate, direct interviewing with participant. The data collection started from first of October 2014 to first of September 2015. The constructed instrument used is compromised of two sections: section one includes the nurses demographic characteristic, section two is the documentation tool which consists of 4 parts including (vital signs form, nursing observation flow sheet, intake-output fluid flow sheet and insulin chart).Descriptive and inferential statistical methods were used to analyze the data. Reliability of the instrument was done for the tool parts and flow sheets through test and retest, also a panel of experts determined the validity of the tool. data was analyzed by using descriptive and dataResult: The study showed that the majority of nurses were male, with age group (30-39), they graduated from the school of nursing (50.7%), they had (1-4) years of experience in medical wards (22.5%). Most of the study sample had sharing in training sessions related to documenting in nursing (80.3%).Conclusion: Overall evaluation for the documentation of the nursing staffs is moderate.Recommendations: the study recommended to- Applying the modified documentation system to all Iraqi medical wards.KUFA JOURNAL FOR NURSING SCIENCES Vol. 6 No. 3 Sep. through Dec. 201620-Training sessions should be conducted for nurses to act as a unique challenge for showing the importance of documentation and documenting nursing activities.
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