Nurses' Performance toward Quality Documentation for Patients in ICU: Suggested Guidelines

Abstract

Background: Nursing documentation is the recording, documenting or charting of nursing care that is planned or given to the patients in intensive care unit (ICU) by qualified nurses. It is any written or electronically generated information about a client that describes the care or service provided to that client. The aims of this study were: 1. Assessing nurses' performance toward quality documentation for patients in ICU. 2. Suggesting guidelines for quality documentation for patients in ICU. Study design: a descriptive study was used to achieve the aim of this study Subject: A convenient sample includes all registered nurses (50). Setting: This study was conducted in intensive care unit affiliated to Mansoura Emergency Hospital Tools: three tools were used for data collection; self-administered questionnaire, nurses’ practice observational checklist and nurses' attitude likert scale. Results and conclusion the results of this study showed that, more than half of the studied nurses had got satisfactory level of knowledge, near three quarter of studied sample had got unsatisfactory level of practice, and more than three fifth had got negative attitude toward quality documentation for patients in ICU. Recommendation Training program including the suggested guidelines toward quality documentation for patients in ICU must be implemented for nurses based on their need assessment, and evaluate its effectiveness on their performance.