Development of a Focus-charting Nursing Documentation Model to Enhance Quality and Nurse Satisfaction: A Case Study of a Special Patient Care Unit, Debaratana Nakhon Ratchasima Hospital

Abstract

Nursing documentation is a critical component of quality patient care, requiring completeness, accuracy, and consistency with professional standards. It also has legal implications and affects patient safety. Due to an issue with incomplete documentation among professional nurses in the special ward of Debaratana Nakhon Ratchasima Hospital, the researcher conducted developmental research aimed to develop and evaluate the effectiveness of a focus-charting nursing documentation model based on the nursing process and Deming's quality management cycle. The study involved 17 professional nurses working in the special ward of Debaratana Nakhon Ratchasima Hospital and was conducted from March 2024 to February 2025. Research tools included focus group discussions for model development, a knowledge test, a documentation quality checklist, and a satisfaction questionnaire. Data were analyzed using descriptive statistics and t-tests to compare  documentation quality before and after implementing the model.

The results showed a marked improvement in the nurses’ knowledge and skills in nursing documentation after training and six months after implementing the developed model. The participants reported high satisfaction with the model, which led to more complete and accurate nursing records, reduced the likelihood of errors, and enhanced the effectiveness of patient care. This study highlights the benefits of applying the Deming Cycle and the nursing process to improve documentation quality, providing a practical framework for sustainable healthcare quality management in alignment with professional standards.