การพัฒนาคุณภาพการบันทึกทางการพยาบาล ห้องผ่าตัด โรงพยาบาลแพร่

Abstract

Quality of nursing documentation is an important indicator demonstrating that nurses have achieved standards of nursing practice. This developmental study aims to improve the quality of nursing recording in the operating room at Phrae hospital, Phrae province, using the continuous quality improvement process, FOCUS-PDCA (FOCUS-PDCA: find, organize, clarify, understand, select, plan, do, check, and act). The population included 4 senior professional nurses who were a member of the quality development team and 28 professional nurses who were in the nursing documentation team. The sample group included the nursing records of inpatients undergoing surgery in the orthopedic and obstetrics departments in the operating room at Phrae hospital. Forty records were selected using simple random sampling after the implementation from February 1, 2023 to March 31, 2023. The tools used for this study included: 1) an interview guide asking about nursing recording problems in the operating room at Phrae Hospital, 2) a questionnaire for collecting nurses' opinions regarding the use of the nursing record form, 3) the focus charting nursing record form and the focus charting nursing record manual developed for this study, and 4) a quality checklist for auditing nursing records. The study results revealed that, after the quality improvement implementation using the FOCUS-PDCA process, the quality of obstetrics and orthopedic departments’ nursing documentation was complete and met the standard criteria at 93.25% and 89.00%, subsequently. The nursing documentation of both departments reached the standard criteria which was specified at higher than 80.00%. This study showed that through the continuous quality improvement processes, FOCUS-PDCA, the quality of the obstetrics and orthopedic departments’ nursing documentation, in the operating room at Phrae Hospital, was improved effectively. The focus charting nursing record form and the manual should be applied in other departments. The quality development team, as well, should regularly evaluate the quality of nursing records in order to continuously improve the quality of the nursing documentation in the operating room.