Comparing Effect Two Methods of Documentation the Problem Oriented Medial Record and the Traditional Record on Characteristics Nursing Progress Note

Background and Nursing documentation is the nurses professional task and one of important component of patients file and a documentary report of patient condition, progress of disease, nursing cares and the patients response approach. So, it must be complete, factual & accurate, organized & legal guidelines for recording. Today, it is recorded in different methods. The studies carried out in Iran show the quality of nursing documentation are low. The objective of this study is comparing the effect of two kinds of nursing documentation, POMR and Farabi specialty hospital under supervision of Mashhad social security organization in autumn 1385. In this one-group only post test study clinical trial, the purposeful sampling was used; 38 subjects were selected randomly and divide into two groups. They were asked assess their patients by the assessment tool and record their nursing documentation in one of two kinds. For at least 3 patients of the odd beds number in on of two methods and in the other week in other method. Finally, one documentation selected from all nursing records of each nurse on each method and compared with check list. Based on findings there was a significant difference between characteristics of POMR and traditional method so that the total score of POMR can improve the quality of nursing documentation. According to results of this study, the problem oriented medial record method was more effective than the traditional record on characteristics nursing progress note.