การพัฒนาคุณภาพการบันทึกทางการพยาบาลในหน่วยงานอุบัติเหตุและฉุกเฉิน โรงพยาบาลเถิน จังหวัดลำปาง

Abstract

The record in nursing documents is an important element which allows for the continuing care of patients. The purpose of this study was to improve the quality of nursing documentation in an Emergency Unit, Thoen Hospital, Lampang Province. The study methodology was guided by the FOCUS-PDCA quality improvement process (Deming, 1993 as cited in McLaughlin & Kaluzny, 1999) which consisted of 9 steps: find a process to improve; organize a team that knows the process; clarify current knowledge of the process; understand causes of process variation; select the processes for improvement; plan the improvement; do the improvement; check the results, collect and analyze data; and act to maintain and continue improvements. The study population included 11 registered nurses. The research instruments included an interview guide and a quality assessment form for nursing documentation, which were developed by the researcher. Data were analyzed using descriptive statistics. The FOCUS PDCA process helped the researcher to develop new forms using the checklist format to facilitate the completion of documentation related to nursing assessment of admission and discharge. Manual of using such forms were also developed. After implementation of the new forms for one month, the researcher reviewed the nursing documents. Results revealed that the quality of nursing documentations increased from 35.02 % to 86.28 %. However, there were some problems arised during the quality improvement process including: 1) developed forms were difficult to record in the opinion of some nurses; 2) at the end of the study, some nurses were still unfamiliar with the new nursing documentation forms; 3) some nurses still did not understand how to fill the data into the forms; and 4) a record of the nursing documents wasn’t continuously monitored. This study revealed that the FOCUS PDCA quality improvement process is effective in improving the quality of nursing documents. It was recommended that nursing administrators should use this quality improvement process to improve the quality of nursing documentation in the other departments of the same hospital.