Development of nursing documentation of pneumonia patients in Inpatient Units at Kham Ta Kla Hospital, Sakon Nakhon Province.

Abstract

Objectives: The study aimed to improve nursing documentation of pneumonia patients in Inpatient Units at Kham Ta Kla Hospital, Sakon Nakhon Province and compared mean score of documentary quality before and after the process of development.

Materials & Method: The developmental research used PDCA (Plan-Do-Check-Act) process. The Sampling were 15 register nurses who work in Inpatient Units at Kham Ta Kla Hospital, and 40 documentary of pneumonia patients before and 40 documents after the improving. Data was collected on the month of September to October, 2021. The instruments for collecting the data included the form of nurse demographic data, the audit checklists assessing the quality of the recording data, and the nurse satisfaction questionnaire of using the improving documentary of pneumonia patients. The data were analyzed by content analysis and descriptive statistics comprising frequency, percentage, mean and standard deviation. A comparison of mean scores of the quality recording before and after the improving were analyzed by using independent t-test.

Result: 1) the problem of recording was not have focus documentary form of pneumonia patients, the register nurses lack of recording skills and knowledge about pneumonia disease 2) improving the pneumonia documentary form and setting documentary manual with sample of recording nursing activity for pneumonia patients consisted the form of first time admitted, focus list, nursing progress note and discharge plan, 3) teaching about pneumonia disease and training  skill of register nurses to record all of the improving pneumonia documentary forms 4) Mean score of the quality audit chart after the improving higher than before significantly ( =23.95, S.D.=2.14 vs =19.83, S.D.=1.84; t=-9.258, p<0.01) and 5) the satisfaction of register nurses to use the improving documentary of pneumonia patients was the highest ( =4.60, S.D.=0.51).

Conclusion: The study showed the development of nursing documentary with PDCA process improved skill of the register nurses to record nursing care with pneumonia patients effectively.