The Development of Focus Charting Nursing Documentation on Quality of Nursing Documentation and Satisfaction of Professional Nurses in Operating Rooms in a Private Hospital
Keywords:
Nursing documentation, Focus charting, Quality improvement of nursing recording, satisfaction of professional nurses, Perioperative nurseAbstract
This action research aimed to study developing the focus charting nursing documentation on quality of nursing documentation and the satisfaction of professional nurses in operating room in a private hospital. The population and target groups in this study were divided into three groups: 1) development team, 2) operations team, 3) nursing documentations. The research instrument was examined and the content validity index (CVI) was equal to 0.92 and the reliability value was equal to 0.94. The research data was analyzed using descriptive statistics (frequency, percentage, mean) and inferential statistics (Paired t-test)
Analysis of the nursing documentation show 4 important issues: 1) Recorded information is irrelevant to the patient’s actual problem; 2) Recording of nursing practice corresponding to a problem is not sufficiently comprehensive; 3) Recording is incomplete and not indicative if a problem has been solved; 4) There is no nurses’ documentation manual specific for operating room patients. The quality of nursing documentation prior to launching the focus charting recording approach based on the Plan-Do-Check-Act (PDCA) cycle developed in this study was at a low level ( = 1.95, SD = 0.42) Implementation of the newly-developed form results in improved quality to a moderate level (
= 3.11, SD = 0.73) as well as improved nurses’ satisfaction of the recording format. The overall satisfaction average score has been improved to a high level (
= 3.23, SD = 0.68) This study demonstrates that application of focus charting nursing documentation in the Operating Room context is an innovative approach. Focus charting documentation should be considered for application to Operating Room nursing documentation to better understand the specific problems of individual surgical patients in order to provide appropriate nursing care during every stage of the operation.
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