Development of a Nursing Documentation Form of Pediatric Intensive Care Unit, Phramongkutklao Hospital

Abstract

This is a research and development study. The purposes are to develop a nursing documentation form for pediatric intensive care unit in Phramongkutklao hospital and to explore satisfaction of users utilizing the documentation form. The population were sixteen registered nurses and one pediatrician. The research instruments consist of the interview to explore needed information in developing the nursing documentation form, the questionnaire of satisfaction in using the nursing documentation form, and the completeness of recording based on nursing documentation form checklist. Statistics analyzed data are percentage and standard deviation. The results showed that the nursing documentation form developed by implementing nursing process and Roy’s Adaptation Theory includes five parts; Nursing admission database for pediatrics, Nursing care plan part I: Assessment and problem list; Nursing care plan part II: Pediatric critical form, Nursing care plan part III: Nursing progress note and Patient discharge summary. The usages’ satisfaction of the nursing documentation form demonstrated that the mean of overall satisfaction was at a medium level ( = 3.71, S.D. = 0.53). The satisfaction with recording in Part four had the highest score ( = 4.18, S.D. = 0.64) and the satisfaction with spending time recording had the lowest score ( = 2.81, S.D. = 0.81). The developed nursing documentation form is a tool for recording important data being used for treatment and nursing care and communicating between the health care team. For further study, the self-concept mode and the role function mode in infants and young children patients should be improved.