The effectiveness of using computer programs for nursing documentation on nursing documentation quality and the integrity of inpatient medical records at Phrathongkham Community Hospital Commemorating His Majesty the King's 80th Birthday Anniversary, Nakhon Ratchasima Province.
Keywords:
computer programs, nursing Documentation quality, Integrity of inpatient Medical RecordsAbstract
High-quality nursing records serve as a reliable reference for clinical and legal practices, facilitating effective communication among healthcare professionals, and ensuring continuity of patient care. This retrospective study aimed to investigate the effect of a computerized nursing record program on the quality and completeness of inpatient medical records in Phra Thongkham Chaloem Phra Kiat 80th Birthday Anniversary Hospital, Nakhon Ratchasima Province. The sample group consisted of 350 computerized patient medical records recorded between October 1, 2021 and September 30, 2022. Data collection was conducted from February to April 2023. The research tools were computerized nursing recording software, a questionnaire for assessing the quality of nursing records, and an audit checklist for evaluating the quality of inpatient medical records. The content validity of the tool was 0.88 and its Cronbach's alpha reliability coefficient was 0.82 Data analysis was performed using descriptive statistics.
The research findings revealed that the overall quality of the computerized nursing records was at the highest level. The quality of the nursing records regarding adherence to the nursing process was at a good level, while the quality of recording records in accordance with the nursing process and the continuity of recording were at a very good level. Furthermore, the overall completeness of the inpatient medical records was also found to be at a very good level. The highest and lowest completeness of records were that of the discharge summary records and informed-consent records, respectively. In summary, the computerized nursing record program contributes to enhancing the quality of nursing documentation and the completeness of patient medical records to improve the outcomes of care.
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