การพัฒนาคุณภาพการบันทึกทางการพยาบาลในหอผู้ป่วยกระดูกหญิง โรงพยาบาลนครพิงค์ จังหวัดเชียงใหม่

Abstract

Nursing document serves as important evidence that shows nursing care provided to patients; it can also be used as a form of communication among nursing personnel. Effective nursing documentation is therefore crucial for nursing practice. The purpose of this developmental study was to improve the quality of nursing documentation in the Female Orthopedics Ward at Nakornping Hospital. Study methodology was guided by the FOCUS PDCA improvement process (Deming,1993 as sited in McLaughlin & Kaluzny, 1999) which consists of nine 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 improvement; plan the improvement; do the improvement; check the result, data collection and analysis; and act to hold the gain and continue improvement. The population in this study was 11 registered nurses. The research instruments included an interview guide and an assessment form for nursing documentation which were developed by the researcher. Data were analyzed using descriptive statistics Results revealed that FOCUS PDCA methodology were able to improve nursing documentation in this study. The process helped nurses identify the causes of uncompleted nursing documents and select appropriate actions to solve identified problems. The researcher developed practice guidelines for nursing documentation and trained nurses for practice compliance with the guidelines. One month after implementation, a chart audit was done by the researcher and the quality of nursing documentation increased from 41.64% to 83.70%. The results of the study show that FOCUS PDCA methodology helps to improve the quality of nursing documentation. Administrators can apply it to improve quality of services in their departments and other departments in the organization.