Abstract
Background: principals of communicating information among healthcare providers are through patient care documentation. Accurate, timely, thorough and concise documentation can be the deciding factor for whether a patient lives or dies. Aim: The present study was aiming at utilizing training as a means for improving staff nurses’ documentation skills. Subjects: 63 nurses were included in the study. Setting: The study was conducted at inpatient units at Al Helal hospital. This hospital is affiliated to Ministry of Health Specialized Medical Centers. Methods: three tools were used to collect data for this study. Knowledge assessment questionnaire, an observational checklist, Pre and post-test simple questions according to the title of each session. Results: slightly more than two fifth of staff nurses had high level of knowledge regarding total documentation dimensions in preprogram phase, while all staff nurses had highly knowledge in post phase and slightly decline at follow up phase with highly statistically significant improvement with all the phases of intervention. majority of staff nurses had low total performance level at preprogram phase while four fifth of them had high performance level at post phase and three quarter of them had high performance level after three months of training intervention with highly statistically significant improvement in total documentation performance level with all the phases of intervention. Conclusion: There was highly statistically significant improvement in total staff nurses’ documentation knowledge and performance level during post and follow up phase as compared with preprogram phase. This supported the study hypothesis which stated, staff nurses documentation skills will be improved after implementing the training intervention. Recommendation: dissemination of manual for new staff nurses contains documentation skills. Dissemination of information and research finding should be done online to improve its utilization.
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