Nursing Documentation Requirements in Coronary Care Unit

Considering the importance of correct documentation in taking care of the patients especially in Coronary Care Unit (CCU), this study aimed at explaining nursing documentation requirements in CCU for improving the reporting system.

It’s a qualitative content analysis study, 15 qualified nurses and 15 qualified instructors from Iran were selected through purposeful and snowball sampling method in 2013. They explained documentation requirements in the CCU by using open-ended questionnaire. One note software was used for data analysis.

After data analysis, 22 subcategories from 5 main categories were emerged as documentation requirements in CCU: (1) health history, (2) health evaluation, (3) monitoring, (4) nursing interventions, and (5) nursing discharge notes.

On admission information regarding health history, findings achieved from patient’s health assessment in different situations such as; a. at the beginning of admission, b. at the beginning of every shift and c. Discharge time, also information achieved from patient’s monitoring during shift; nursing interventions done for the patient and discharge time report are counted as nursing documentation requirements in (CCU).