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The Influence of Nursing Process and Documentation Training on Implementing of Nursing Process Documentation In Bireuen District Hospital

DOI : https://doi.org/10.36349/EASJNM.2020.v02i02.003
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Documentation is an important aspect in nursing practice. Hospital Accreditation National Standard (SNARS) Edition-1 requires that patient care plans must be created and documented, and documentary evidence can be reviewed in the patient's medical record. Many obstacles have been faced by nurses in implementing nursing process documentation properly, including the lack of competence and lack of training in documenting the nursing process. The purposes of this study are to assess the influence of nursing process and documentation training on nurse’s knowledge of nursing process and documentation, and to assess the influence of nursing process and documentation training on implementing of nursing process documentation in patient medical records based on SNARS Edition-1. This is quantitative research with one group pre and posttest design. Samples are 68 nurses taken by purposive sampling according to criteria established by researchers. Patient medical record samples totaling 68 medical records. Data were analyzed by Paired T-Test to compare the value of pretest-posttest nurse’s knowledge and pretest-posttest implementation of nursing process documentation in the same sample group. The results show that there is a significant increase in nurse’s knowledge about nursing process and documentation before and after training (p-value=0,000), a significant increase on implementing of nursing process documentation before and after training (p-value=0,000). In conclusion, the nursing process and documentation training is able to increase nurse’s knowledge about the nursing process and documentation, and can improve implementing of nursing process documentation.

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Dr. Afroza Begum

Lecturer, Dept. of Pharmacology and Therapeutics, Shaheed Monsur Ali Medical College & Hospital, Uttara, Dhaka-1230, Bangladesh

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