Quality of nursing documentations in CCU by hospital information system (HIS)

Nursing documentations describes quality of nursing care delivery. One of the development indicators of health care is the existence of hospital information systems (HISs). The aim of this study was evaluation of the quality of nursing records through an electronic information system in the CCU in one of the educational hospitals in Lorestan.

This study is a participatory action research. It was done in order to enhance quality of nursing documentations through four phases. This study was done on 630 recorded nursing documentations in 70 files existed in electronic information system of the hospital by using census method in 2011. The data gathering tools was the observational checklist of recorded nursing cares included 127 items in functions of vital systems, general cares and patient education. Data analysis was done by descriptive statistics.

Change in vital signs, chest pain, disrhythmias, patient’s appetite, amount of infusion and transfusion and changes position of more than 70%, dedicated maximum frequency of the complete record. But the possible complications, nursing interventions, patients’ responses to these interventions after infusion and transfusion and teaching drug diets hadn’t been recorded in any of the nursing documentations completely. Respiratory disorders (34.3%), anxiety and restlessness (35.7%) had the lowest frequency of complete recording, in spite of their high importance in CCU.

Using the HIS, in some cases, the quality of nursing documentations is in high level, but according to the existing facilities, the enhancement is possible. Furthermore, it is recommended to prepare ready nursing documentations forms, place the network on the electronic portable devices or on the patient’s bedside, remote access of health team and accomplish applied researches.