Quality and barriers against nursing documentation in Kashan Shahid Beheshti Hospital(2011)

Accurate and complete documentation of nursing reports is the precondition for evidence-based care and one of the most important duties of nurses. Besides، it has a decisive r ole in the quality of nursing care and improves the relationship with other health team members. The object of the present survey was to evaluate the structure and content of nursing reports and reasons of incorrect reporting in Kashan Shahid Behashti hospital in 2011. In this cross-sectional study، 140 nursing documents were evaluated. The records were randomly selected from the Intensive care unit، internal medicine ward، and surgery ward. A checklist designed according to the eleven principles of nursing documentation and had 38 items was used in order to evaluate the quality of nursing documentation.. In the checklist، 30 items referred the content and 8 regarded the structure of documentation. To pinpoint barriers in nursing documentation، a previously self-designed questionnaire was applied. The obtained data was analyzed using SPSS software (V: 11. 5) and statistical tests and Chi-square at the significant level P<0. 05. Among the documents 21. 4% had a favorable quality، 53. 6% had moderate quality، while the quality of 25% was weak. In the hospital mentioned، t otal content quality of nursing documents was low but that of structure was acceptable. According to nurses، nursing staff shortage، fatigue، high workload، and the documentation''s lack of impact on employment promotion and nurses'' giving priority to patients'' care rather than documentation، occupational problems، lack of knowledge of the principles of writing correct documentation، and not knowing legal consequences were the most reasons for or barriers against accurate and due documentation. The content of nursing documents was not satisfactory and requires improvement.