Establishment And Application Of Nursing Documentation System Based On Mobile Nursing Concept

ObjectiveThis descriptive study aimed to simplify the nursing document as a starting point and make the clinical nursing practice as the foothold in clinical practice assessments. Thus, we can construct the nursing document system with characteristics and features of College Hospital to improve the quality of care and patient satisfaction. The "programme of activities of high quality nursing service demonstration project" will be implemented as solid foundation.Method1. Establishment of nursing documentation system. The study was to investigate documentation of nursing as objects in hospital ward. With the convenient sampling method, we selected one hospital for researches.The hospital is one three A-level hospital affiliated the Ministry of Education in985colleges. The nursing records included six representative wards, involving department of cardiology, general surgery,obstetrics and gynecology, pediatrics, respiratory and ICU. The nursing documents was designed into tables under medical writing specifications. Through clinical practice, feedback from nurses and repeated revision and improvement, the form of nursing documents will be popularized to clinical in March,2012.2. Application of nursing documentation system. The form of nursing document was recorded through suspending A4paper in each ward bed. The nurses made "(?)" or concise written records in the ward visits or nursing operation in bed according to the need of patient selection table in the plate holder. A "(?)" has been performed according to the specific situation of various forms.ResultThe writing time decreased by the same nurse by application of new nursing document system. One nurse collected nursing records from the same patient with traditional form of nursing documents and tabled nursing documents. After6months of clinical implementation, a total of100nurses and20patients were questioned. The recovery rate and effective rate were all100%.The results showed a statistical significance in writing time between two methods(P<0.01). The satisfaction degree of patients and nurses and the quality of nursing all improved.ConclusionStandardized and tabular nursing documents are necessary to ensure quality care demonstration project implementation. The research classified and analyzed nursing documents in hospital ward with scientific, rigorous and standardized. We set up the document system in clinical practice and obtained the approval and affirmation of clinical nurses and expert. Furthermore, we laid the foundation for promoting and standardizing the nursing records of language standardization. However, the current form of nursing document still has many deficiencies. We need sum up and foster strengths and circumvent weaknesses, regulate the use and ensure the real objective, integrity and dynamic content of nursing records in clinical work.