The development of Nursing documentation for specific diseases: Inpatient department Chaturaphakphiman Hospital

Abstract

Purposes : To study the situation, develop a model and study the effectiveness of a nursing recording format specific to important diseases, inpatient building, Chaturaphakpiman Hospital.

Study design : Research and development (Research and development)

Materials and methods: Study of professional nurses with 1 year or more of work experience working inpatient department Chaturaphakphiman Hospital. There were 20 participants who met the inclusion and exclusion criteria, we were conducted between March -  November 2023 and analyzing the data, using descriptive statistics frequency, percentage, mean and standard deviation. And inferential statistics, Paired sample t-test, statistical significance was set at 95% confidence interval.

Main finding : 1) 70 percent of professional nurses have never received training on nursing recording standards 60% had received training in caring for mid-term stroke patients and 50.0% had received training in caring for bloodstream infections. 2) Specific patterns of 2 important disease groups, consisting of: Mid-stage cerebrovascular disease (IMC) patients and patients with bloodstream infections (Sepsis) and 3) The results of the evaluation comparing the average quality of quantitative nursing recordings for disease-specific formats with general formats found that the overall quality of nursing recordings for specific formats had an increased average. The original format had a mean of 82.6 (SD.=22.6.), the specific format had a mean of 90.2 (SD.=19.7), and they were satisfied with using the original nursing recording format. and disease-specific nursing recording formats statistically significant difference (p<.001).

Conclusions and recommendations : This research is a model for development nursing recording formats in other disease groups to ensure the quality of nursing services, continuous development.