Investigation of the nursing document quality in Harbin general hospitals

Abstract

Objective To find out the defects of nursing documents and the interrelated causes and to propose measures for improvement through investigating the status of nursing documents quality of 10 general hospitals in Harbin, with the aim of providing valuable reference for sustainable improvement of nursing documents. Methods Using stratified sampling method, five secondary general hospitals and five tertiary general hospitals were randomly selected in Harbin. Nursing documents of general surgery and cardiac care were investigated, 909 nursing documents from November 2008 to May 2009 were researched, including 262 documents of surgical department and 265 cases of medical department in tertiary hospitals. Surgical department 178 and medical department 204 in secondary hospitals. Combined literature method, spot field investigation and personal interview , the status were researched, the data were analyzed. Results The nursing documents quality assessment of the objective hospitals showed that: the average scores of surgical departments and medical departments in tertiary hospitals were 97. 20 and 97.26, respectively; scores of surgical departments and medical departments were 97.64 and 98.22 in secondary hospitals. The medical documents qualities of the secondary hospitals were better than the tertiary hospitals'; The surgical nursing documents qualities had statistical difference. Critical care nursing records had the best quality. The main problems are: scratch, sticky,coating, the wrong date, the content of records are incomplete, illegible handwriting, the wrong records of the dynamics of blood pressure, and so on. Conclusions In general hospital of harbin city, the overall quality of nursing documents are good, but there are still some problems. The main causes of nursing documents defects are the shortage of nurses, awareness of the law, indifferent sense of duty, nurses professional and cultural qualities which need to be improved, lack of health care communication and insufficient administrative supervision. Key words: Nursing documents; Assessment of nursing documents quality; Nursing management