Abstract

Background: Standard and comprehensive documentation is the first condition of good care of the patient. By documentation, patients' needs in different aspects can be identified and met and the effectiveness of nursing actions may be evaluated. Aim: This study aimed to determining the quality of nursing documentation in CCU of the hospitals affiliated to Shahid Beheshti University of Medical Sciences in Tehran, capital city of Iran. Method: It is a descriptive study which was carried out in June, July and August of 2017. The research sample was included 98 nurses working in the mentioned ward which had been selected by total counting method. Then, four documents of the last document of each nurse were evaluated using the researcher-made checklist based on documentation standards. The research tool consisted of three parts including demographic information, structure and content of documentation which was validated by the experts in terms of face and content validity. Tool reliability was also done by agreement between the observers with a reliability coefficient of 0.9. Descriptive statistics, independent t-test, ANOVA test and Pearson Correlation coefficient were used in SPSS 20 software. Results: The results showed that in the structure domain, 69.1% of documents had very good qualities. 49% of the documents in the content domain had also good qualities. In general, 28.4% had moderate, more than half (59.4%) good and only 12.2% had very good quality. There was a significant relationship between the qualities of nursing documentation with the female sex (P: 0.001), Master's degree (P=0.001), participating in the documentation training courses (P: 0.005) and weekends and holiday (P: 0.003) and also there was a significant reverse correlation with age, work experience and overtime hours (P<0.001) (r: -0.2). Implications for practice: According to the results, more of the nursing documents in the structure domain had very good qualities as well as moderate and good qualities in the content domain. There is still a need for planning to improve the quality of nursing documentation in some structure and content standards.