Quality Patient Care Is Frequently Measured The Communication Systems Prevalent in Nursing Units. Through Analysis of

Accreditation Agencies Frequently Use Nursing Records Documentation of Nursing Activities Documentation of Nursing Activities Objective Measures of Quality of Patient Care. As

Proper Documentation Tools Are Essential to Help Nurses in Better Communication And Hence And Hence

Refers to the Preparation and Maintenance of Records That Describe a Patient Care.

In Nursing Can Be in Form of Either WrittenOral Documentation of Nursing Care or

..Where As R ecording Involves Written documentation of the pertinent. Significant aspects of all facts of daily care. Status of the patient’s condition throughout that time period

While.. R eporting Is A Form of Oral Documentation That Summarizes the Care and the Patient Status

As Both Forms of Documentation Facilitate Continuity of Care Allows Rapid Sharing of Patient’s Data That Assure the Use of Current Information in Clinical Decision Making Reporting

Provides a Permanent and Complete Document of Patient’s Care Activities. Recording While

In General It Has Been Observed That Few Nurses Give Little Attention to Documentation Tools

The Communication System in Patient’s Units That Assess Nursing Personnel Learning Needs for Documentation and Communication May Help in Identifying the Needs for Developing a Manual That Provide Directions and Guide Lines for Nursing Personnel

And this is to Upgrade Their Communication Skills Improve Documentation Improve Their Quality of Patient Care

 Assess availability of different nursing records and reports currently in use in the General Medical & Surgical units of Alexandria Main University Hospital and pattern of Documentation.  Assess nurses opinions regarding pattern of communication in such patient care units.

 Assess Nurses’ Knowledge and Learning Needs for Effective Communication and Documentation System  Develop a Manual to Meet The Identified Needs

The study was conducted at the general medical and surgical units of the Alexandria Main University Hospital. The study was conducted at the general medical and surgical units of the Alexandria Main University Hospital. Two general medical and two general surgical units were randomly selected for the study. Two general medical and two general surgical units were randomly selected for the study. The study covered all nurses who were available in the selected units at the time of the study. The study covered all nurses who were available in the selected units at the time of the study.

A representative sample of medical records of patients admitted at the selected units during the data collection period that extended over one month. A representative sample of medical records of patients admitted at the selected units during the data collection period that extended over one month. Forty medical records were selected, 10 from each unit.Forty medical records were selected, 10 from each unit. The criterion for selection was that the patient had to be hospitalized for at least one week.The criterion for selection was that the patient had to be hospitalized for at least one week.

A) Checklist for Auditing Patient’s Record Was Developed by the Researcher Based on the Review of Current Relevant Literature

It is used to collect data regarding: 1. Availability of nursing records and reports used by nursing personnel in the unit. 2. Pattern of documentation.A 3-point scale was used to judge the adequacy of documentation. 2 stands for Adequate 1 stands for Incomplete 0 stands for No Documentation

B) Another Checklist Was Developed to Assess Nurses’ Opinion Regarding Pattern of Communication Prevailing in Their Units.

C) A Questionnaire Was Developed to Assess Nurses’ Knowledge and Learning Needs Regarding Communication Process, Principles of Proper Documentation, Recording and Reporting Methods and Their Importance and Benefits. A 3-point scale was used to judge the adequacy of documentation. 2 stands for Adequate 1 stands for Incomplete 0 stands for No Documentation

Based on the identified needs, a Manual was developed. The contents of the Manual were developed with the help of current literature, taking into consideration the educational background of the nursing staff and the general principle of adult education.

Data Were Collected Through: Data Were Collected Through: 1. Concurrent review of the patients’ medical records as well as reports used by nursing personnel in the selected units to assess availability of different types of nursing records and reports and pattern of documentation.

2. Questionnaire interview with each individual nurse working at the selected units to assess the nurses’ knowledge and learning needs regarding documentation process and system. ??????

3. The Content Validity of the Developed Manual Was Assessed by a Jury of Expert Nurse Educators and Then Administered to the Head Nurses of the Selected Units.

4. Educational Sessions Were Conducted With the Head Nurses to Clarify the Purposes of the Manual and How It Can Be Applied in Their Clinical Areas.

Availability of Nursing Records in The General Medical and Surgical Units A- Records

Plan of Care Forms For Example Medical Order  Nursing Care Plan  Teaching Plan  Kardex Form 

Other Clinical Nursing Forms: For Example Vital Signs Record  Fluid Balance Record  Diabetes Record (Insulin Chart)  Diabetes Record (Insulin Chart)  Coagulation Record  Nursing Medication Record  Narcotic Record 

B- Reports Availability of Nursing Records in The General Medical and Surgical Units

Adequacy of Documentation of Nursing forms at Medical Surgical Units

Percent Distribution of Nurses’ Knowledge and Their Learning Needs Regarding Communication Process.

Percent Distribution of Nurses’ Knowledge and Their Learning Needs Regarding Reporting.

Percent Distribution of Nurses’ Knowledge and Their Learning Needs Regarding Recording.

A. Communication with Physicians: 1. Physician’s Orders Physician orders are Clear Abbreviations used by physicians are known Type Written orders Oral orders Type Written orders Oral orders

Written Orders : a. in patients medical records b. in other forms Written Orders : a. in patients medical records b. in other forms Oral Orders.

A. Communication with Physicians: 1. Discussion of Patients Condition During Daily Conference During Clinical Rounds

B- Communication Among Nurses 1. Shift Reports 50 12

2. Assigning Duties Person Responsible for Assigning Duties. Head Nurse Senior Staff Nurse

Type of Assigning Duties Oral 80% Not Done Written 0%

Special Records Phone Calls C- Interdepartmental Communication:

Improve Nurses’ Documentation Skills Improve Nurses’ Documentation Skills Documentation Manual Documentation Manual Enhance Quality Patient Care

Based on the Findings of the Study, The Following Recommendations Would be Suggested:

1 The Developed Manual should be used on an ongoing basis. It should be administered to each newly employed nurse to: Refresh her knowledge. Develop an insight of her role regarding the documentation system and its importance. It should be administered to each newly employed nurse to: Refresh her knowledge. Develop an insight of her role regarding the documentation system and its importance.

2 To Help Nurses to apply the developed manual, the different forms of nursing records and reports suggested in the manual should be made available to nurses by the hospital or health authority and be kept as a permanent data source.

3 Proper Supervision must be continuously performed by the head nurse to ensure that nurses utilize the documentation system in a proper and consistent way.

4 Physicians must take into their consideration reports and records written by nurses to encourage them to use documentation of the nurses’ forms.

5 There should be strict hospital and rules to control nurses negligence of recording and reporting.

THANK S