Audit of Nursing Documentation Reports in Intensive and General Wards of Medical Education Center of Shahid Yahyanezhad

Nursing reports is one of the most important legal documents that representthe general condition of patients. Nursing reports should be complete and precise; because you can rely on the time of accusation on. In this survey, we want to audit the nursing reports in intensive and general wards. This survey is cross-sectional which asses the patient’s case in general and intensive wards with an evaluated checklist of health ministry. Our survey includes 250 patient’s case and nursing reports of 124 nurse consist of 105 women and 19 men. This survey showed that the mean score of reports was 54.77±38.12. Nurses with a master degree were significantly higher scores than nurses with a bachelor degree (P=0.047). Mann-Whithney exam results showed no significant difference between general and intensive wards (P=0.187). The nurse’s efficacy with experience less than 10years was more than others (P=0.001). In general the relationship between education level and precision is obvious so the role of education with higher quality was undeniable, although we can trust younger nurses.