The efficacy of focus charting in enhancing the caliber of nursing recordings and nursing recording quality Hospital Nong Phok, Roi Et Province

Abstract

Purposes : To analyze the situation, develop quality and study the effectiveness of  specific nursing care focus charting record (Focus charting Record).        

Study design : Action Research.        

Material and Methods : The population and sample consisted of 13 professional nurses working at the inpatient building. Purposive sampling of in-patient medical records during day 1 March - April 30, 2023, 339 charts, selected according to criteria sort out A sample group of 164 charts were obtained. The tools used in the research were: Recording Quality Assessment Questionnaire focus charting nursing record qualified person. The content validity index (CVI) was equal to 0.90. Data were analyzed using descriptive statistics, including percentage, mean and standard deviation.        

Main findings : Focus charting nursing outcomes situation analysis. The module does not cover either A-I-E (Assessment-Intervention-Evolution) to discover the patient's real or potential problems. But the lack of documentation causes many parts of the record to be duplicated many times, resulting in a large number of records that do not support the operation of nurses. Quality development, there is a 4-step process: 1. Plan 2. Action 3. Observe and 4. Reflection. Comparative analysis of the mean total scores for quality assessment of nursing records with a quantitative focus charting after development. The mean scores increased from 1.58 to 1.74. Most of them had the mean of complete and qualitative data after development. There was an increase in the mean score from 2.24 to 2.55. Most had the mean of complete information.        

Conclusion and recommendations : This research resulted in clear communication of patient information to the professional team easy to read and shorten recording time Supervisors should assign professional nurses to continuously review specific nursing records to achieve the development of nursing quality.