Quality improvement of nursing documentation in the obstetrics and gynecology department 1-2 Regional Health Promotion Center 1 Chiangmai

Abstract

Nursing documentation is an important tool that nurses use to communicate between nursing teams and interprofessional teams to ensure continuous and safe patient care. The purpose of this development study is to improve the quality of nursing documentation in the obstetrics and gynecology department 1-2 by using the continuous quality improvement process, FOCUS-PDCA, which includes FIND a process to improve, ORGANIZE a team that knows the process, CLARIFY current knowledge of the process, UNDERSTAND the source or causes of process variation, SELECT the process to improve, Plan, DO, Check, Act. The sample groups used in this study include the quality improvement team, the nursing documentation team, the quality assessment team, and nursing documentation. The sample selection was purposeful. The study tools used in this study include: 1) personal information questionnaire, 2) nursing professional group meeting questionnaires, 3) nursing documentation quality assessment form, and 4) questionnaire on opinions on the use of developed nursing documentation forms. The data were analyzed using descriptive statistics and content analysis.

The FOCUS-PDCA continuous quality improvement process was adopted to search for a suitable method to understand, analyze, plan, and implement improvements to the quality of nursing documentation. A nursing documentation manual was created and utilized in the process, leading to a statistically significant improvement in the quality of nursing documentation before and after the development (t = 9.54, df = 8, p < .01). The mean value of the group after development (46.33) was higher than the group before development (41.11). Regarding feedback on the use of the developed nursing documentation form, 100% of professional nurses agreed that it was more convenient to use. 88.24% agreed that it was clear and beneficial for their organization, and 82.35% agreed that it was easy to understand.

The researchers concluded their study and presented their findings to healthcare management, recommending the use of this quality improvement process for developing the quality of nursing documentation in other departments of the hospital in the future.