Application of modified nursing documentation system in Intensive Care Unit

Abstract

A patient's medical record (chart) is a legal document in continuity of care and may be used in court as evidence, so it is important that every chart and record must be clear, simple and an accurate language. Methodology: A descriptive study was conducted to apply modified nursing documentation system in intensive care unit (I.C.U.) ⁽⁷⁾.A purposive sample of 50 nurses was selected from intensive care unit at main teaching hospital (Special surgeries, Baghdad teaching hospital, Al-Kadymia, Ibn Al-Nafis and Al-Yarmouk hospital) in Baghdad city from 10^th October 2011 to 30 August 2012.The instrument was constructed and initiated  of two sections; section one includes the nurses demographic characteristic, section two was the documentation tool which consists of 8 parts, first part consist of nursing admission assessment form, part two ventilation flow sheet, part three neuro-sensory flow sheet, part four intake-output fluid flow sheet, part five medication chart, part six wound assessment flow sheet, part seven weaning assessment chart and part eight discharge and health education record sheet. Descriptive and inferential statistical methods were used to analyze the data. Reliability of the instrument was done for the tool parts and flow sheets through test and retest, also a panel of experts determined the validity of the tool.Results; The findings of the study demonstrated that the majority of the sample was from special surgeries and Baghdad teaching hospital, they were married, at diploma and bachelor level of education, they were demonstrated a high percentage of applications to 8 parts of documentation tool, not involved in any I.C.U. Training courses in Iraq nor in a broad. The mean age of the sample was 31.9, ±9.07 years. The mean period of sample employment in intensive care unit was 5.3 years. There was significant association between study variables such as sample hospital distribution, I.C.U. involvement training courses, level of education to application of patient admission assessment form, the study presented significant association between some of study variables and nurses response to application of documentation systems flow sheets such as ventilation, neuro-sensory, wound and weaning, while no significant associate with intake-output, medication and discharge and education record.Recommendations: According to these findings, the research recommended to applying the modified nursing documentation system in all Iraqi intensive care unit., Provide a training course for intensive care unit nurse to practice patient information documentation in an accurate and systemic method and Applying more documentation tools in other hospital department in an electronic method, which is a new trend in nursing settings.