Effectiveness of Feedback Method in Improving the Nursing Documentation in the Emergency Department of Imam Reza Hospital in Mashhad, Iran

Continuous evaluation of medical record documentation is needed for a quality patient care. This study aims to evaluate the status of nursing documentation before and after providing feedback to nurses in the emergency department (ED) of a hospital in Mashhad, Iran.

This quasi-experimental study was conducted in the ED of Imam Reza Hospital in Mashhad in 2022. First, the ED nursing documentation assessment tool was developed based on the literature review and its psychometric properties were evaluated. Then, 150 medical records were randomly selected from the ED and examined by this tool. The results of assessment along with the guideline for correct documentation were given to the nurses as feedback in a video format. One month after, 150 medical records were examined again and the results compared. Data were analyzed in SPSS software, version 22 using the independent t-test, chi-square test, and Fisher’s exact test.

Of 22 indicators in the initial draft of designed tool, 18 obtained acceptable CVR (>0.56) and CVI (>0.79). Cronbach’s α coefficient for the designed tool was obtained 0.85. The mean score of nursing documentation before giving feedback was 27.9±2.1 (out of 36) which increased significantly to 29.1±1.6 after giving feedback (P<0.001). The highest percentage of incomplete documentation was related to the triage form and compliance with the principles of correction or addition.

The status of nursing documentation in the ED of study hospital can be improved by the feedback method. It is recommended to regularly evaluate the nursing documentation status in this department and provide feedback to the nurses.