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RESEARCH PROJECT

PRESENTATION
Presented By:

Sayed Bibi
Sidra Yousaf
Tanveer Akhatar
POST R.N BScN
SESSION 2014-16

PRECEPTOR: Madam Nasreen Ghani


INSTITUITE OF NURSING SCIENCE(KMU)

STUDY TITLE

Importance

of Documentation for Nurses in Clinical


Practice

BACKGROUND

Nursing documentation is a important component of nursing practice and the inter


professional document that occur within the client health record. Documentation
whether paper, electronic ,audio, visual is used to monitor a client progress and
communicate with other health provider
(Ammenwerth,Mansmannm.2013).

The nursing process is a systematic method of planning and providing care to clients. It is
the basis for accurate, complete documentation required to meet legal standards as well as
the standards of care identified in the state nursing practice
(Alfaro-LeFevre,2011).

. Quality nursing documentation promotes effective communication between caregivers,


which facilitates continuity and individuality of care. The quality of nursing documentation
has been measured by using various audit instruments, which reflected variations in the
perception of documentation quality among researchers across countries and settings.
(Ning Wang, David Hailey & Ping Yu.2011).

The electronic health record (EHR) is a documentation tool that yields data useful in enhancing
patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs.
(Mary Ann Lavin, ScD, APRN,2015)

RESEARCH QUESTION

Are staff nurses at Lady Reading Hospital practice nursing documentation


in their daily routine ?

METHODOLOGY

Study Design:

Exploratory Study.

Study setting:

Lady Reading Hospital Peshawar.

Data collection method :

Semi Structured Interviews:


One

time interview of 30 40 minutes was conducted with each research participants

Interview
Probing

Guide was used to interview each participants .

questions were used to get clarity of the concept

Sample size:

15 Research participants( 10 Nurses and 5 Doctors )


o

Document Analysis:

10

documented records from three different wards were analysed .

Study Duration:

Three months

Inclusion Criteria:

All staff nurses who working in three wards (Surgical ,Medical. Orthopedic)
in LRH.

Exclusion Criteria:

Absent or unwilling staff nurses.

DATA ANALYSIS

Familiarizing with Data

Generating Codes

Extracting Themes

Validating from all sources

ETHICAL CONSIDERATION

Informed

consent from research Participants

Collected

data was shared with supervisor only

Participation

Non

was completely participatory

name and other information about the participants were shared in


the write up

SIGNIFICANCE OF THE STUDY

The research has of multiple significances in the field of health education in the
context of Pakistan
This

study provided an opportunity to the researchers to get in-depth understanding of the

documentation in nursing

This study provided researchers an opportunity to identify the best practices of nurses in the
documentation process.

This

study also helped the researcher to explore challenges nurses during documentation

process
The

findings of the study is also helpful for the concerned hospital to explore its best practice

and work on need improvement area in nursing documentation


The

study added to local knowledge about documentation practices in the country

FINDING OF THE STUDY

Nurses definition of Documentation


Recording
Process

and Reporting of information

of confirmation of the procedures

Condition of the patients at the time of recording the information


Medicine they give at the time of their visit
Health procedure taken

Nurses Practices of Documentation in their daily


Temperature/pulse

check and record sheet on regular basis

Record reparation, medication and intake output record .

Nurses perception of documentation in their practical life


Nurses perceive documentation one of the important part of their job
Way to provide accurate and adequate information about patients condition to
the next duty barrier or the physician

Makes them accountable to our legal and ethical responsibility to record and
provide correct information about patients to all concerned including patients,
doctors, and patients relatives

It is an extra burden on us makes our job difficult as we have spent lots of time to
record the information

Challenges Nurses face in Documentation


Work Load
Lack of time
Lack of proper knowledge and skills
No proper chart to document
Challenges

for Doctors
Bad hand writing
Incomplete information
Code words

RECOMMENDATION

More should be research about documentation

Comparative study of documentation process should be in public and


private hospitals in KPK

Comparative study of documentation should be among young and


experienced professional

More hands should on experiences for young learners during their


training

Supervised documentation should during the training and early years


of practice

REFERENCES

Cresswell, J.W. (2000). Qualitative inquiry and research design: choosing among fine
tradition. London: Sage Publication.
Croke, .E. M. (2003). Nurses, negligence, and malpractice. American Journal of
Nursing, 103(9), 54-64.
Denzin, N. K., & Lincolin, Y. (2000). Handbok of qualitative research (2nd ed.).
London: Sage Publication.
Elliott, J. (1991). Action research for educational change. Milton Keynes:
Philadelphia.
Hoban, V. (2003) .How to ... handle a handover. Nursing Times 99(9):5455.
White, L. (2003). Documentation & the Nursing Process. New York, Delmar.