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CODEN : IJPNSD

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Year 2020

Volume: 3 , Issue: 1

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IP Journal of Paediatrics and Nursing Science


Nursing audit conducted to gauge the documentation compliance by nursing professionals at Sagar hospital, Jayanagar within the domain of patient and family education rendered by nursing professionals during the course of their hospita


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Research Article

Author Details : Mary Varghese, Rekha S G*

Volume : 3, Issue : 1, Year : 2020

Article Page : 15-18


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Abstract

Nursing documentation is that the record of medical care that's planned and delivered to individual clients by qualified nurses or other caregivers under the direction of a professional nurse. It contains information in accordance with the steps of the nursing process. It constitutes an integral a part of the nurse’s daily work. Meticulous nursing documentation is a crucial a part of patient care. The delivery of excellent care and therefore the ability to speak effectively about patient care depends on the standard of data available to all or any health care professionals. One important a part of this information is nursing documentation in medical care plans.
Aim of the Study: to gauge the effectiveness of documentation of Patient education process using Nursing audit at Sagar Hospital, Bangalore.
Materials and Methods: The case records were chosen by simple systematic sampling method and every file was analysed employing a structured check list. the whole data were combined into one result for the whole excel sheet. Concurrent patient education form review within the case record were analysed employing a Structured checklist during 1st Nov 2018 to 31st OCT 2019 (12months). Care file were selected employing a simple Systemic Sampling Technique and about 50% of admissions were included within the study and 4317(53.38%) of the entire admission.
Results: Totally compliant were 3726 (86.30%), partially compliant were 399 (9.24%) and non-compliant were 192 (4.44%). the very best compliance of documentation was seen in safe parenting practices, immunization and disease specific information (99.30%). the smallest amount compliance was seen in pain management and documentation 443 (partially and non-compliant category constitutes 11.07%. Data also revealed compliance with disease specific information 99%, medication management 99%, hand hygiene was 91%, pain assessment 81%, fall prevention 62%, pressure ulcer prevention 12%, Immunization 9%.
Conclusion: Use a standardised form will help to make sure consistency and improve the standard of the written account. There should be a scientific approach to providing medical care (the nursing process) and this could be documented consistently. The nursing record should include assessment, planning, implementation, and evaluation of care.

Keywords: Nursing audit, Documentation, Patient education process, Nursing process, Compliances

Doi : 10.18231/j.ijpns.2020.002

How to cite : Varghese M, Rekha S G, Nursing audit conducted to gauge the documentation compliance by nursing professionals at Sagar hospital, Jayanagar within the domain of patient and family education rendered by nursing professionals during the course of their hospita. J Paediatr Nurs Sci 2020;3(1):15-18

Copyright © 2020 by author(s) and J Paediatr Nurs Sci. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (CC-BY-NC 4.0) (creativecommons.org)