الفهرس 
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Abstract
Nursing documentation is defined as the record of nursing care that is planned
and given to individual patients and clients by qualified nurses or other caregivers
under the control of a qualified nurse. In addition, nursing documentation can be used
for specific purposes such as quality assurance. The achieving and maintaining good
standards of clinical documentation is still a problem in the health profession.
The study was conducted to assess the relationship between quality of nursing
documentation and continuity of patient care at university hospitals. This was
achieved through assessing level of nursing documentation quality, assessing level of
continuity of patient care at intensive care units and determining the relationship
between quality of nursing documentation and continuity of patient care at the study
settings.
Research design:
A descriptive correlational design was utilized to conduct this study.
Settings:
The study was conducted at Tanta university Hospitals including the Main
university hospital, Mubark hospital, Emergency hospital and Opthalmology hospital.
The bed capacity of hospital is 650 beds.
Subjects:
The subjects in the study were nurse supervisors, staff nurses at intensive care
units who accept to participate in the study and Patient’s records& concurrent records
of the patients at intensive care units.
Study sample:
1. Convenient sample of nurse supervisors (80 nurse supervisor) was used in the
time of data collection.
2. Simple random sample of staff nurses who give direct patient care and use
records, and reports in ICU units at the university hospitals (80 staff nurses).
3. Patient’s records, concurrent records for (30%) of total record or patient files and
shift report for randomly sample of newly admitted patients during first 24 hrs all
over a three months period (n=80)
Instruments of data collection:
For the purpose of this study, data were collected by using the following two
instruments:
First Instrument: ”Quality of nursing documentation questionnaires:
This instrument aimed to assess the quality of nursing documentation from
nurse supervisors‟ point of view. It is consisted of two parts:
First part: demographic data of nurse supervisors.
Second part: was used to assess level of nursing documentation quality.
Second Instrument: Auditing continuity of patient care checklist:
The aim of this instrument was to assess continuity of patient care by auditing
checklist (observational checklist).It is consisted of two parts:
First part: demographic data of studied patients.
Second part: was used to assess level of continuity of patient care.
Pilot study:
The pilot study was carried out on (10%) of subjects (8 nurse supervisors), also
they were excluded from the main study subjects to fill out the questionnaire. Based
on the results of pilot study, rephrasing of some questions was done to ensure clarity
of questions and to be easily understood by nurse supervisors. The time required for
each nurse supervisor to fill the questionnaires was estimated to be 15-20 minutes.
The purpose of pilot study was to ascertain clarity, relevance, applicability, sequence
of the study instruments.
Fieldwork:
Before beginning to collect data from the study sample the investigator
introduce himself to them, explained the aim of the study and informed them that their
information was treated confidential and used only for purpose of the research.
Additionally, each participant was notified about right to accept or refuse to
participate in the study. Data was collected in the morning and afternoon shift and
subject response to questions in the presence of investigator to ascertain that all
questions were answered. Data was collected upon four months started from January
2020 to April 2020.
Statistical design:
Data were collected, tabulated, statistically analyzed using an IBM personal
computer with Statistical Package of Social Science (SPSS) version 22(IBM corp,
Armonk, NK, USA) where the following statistics were applied.
1. Descriptive statistics: in which quantitative data were presented in the form of
mean ( ), standard deviation (SD), range, and qualitative data were presented in the
form numbers and percentages.
2. Analytical statistics: used to find out the possible association between studied
variables. The used tests of significance included:
* Spearman’s coefficient : is a non-parametric measure of rank correlation (statistical
dependence between the ranking of two variables).it is appropriate for
both continuous and discrete variables, including ordinal variables:
P value of >0.05 was considered non-significant.
P value of <0.05 was considered significant.
P value of <0.001 was considered statistically high significant.
Results:
The most of studied samples resulted in accepted level of nursing documentation
quality (93.7%).
Concerning the mean of nursing documentation quality, importance of nursing
documentation was taken high mean score (28.2).Followed by, types of nursing
records formats availability was taken second high mean score after the mean of
importance of nursing documentation (25.8). While, reasons of unavailability of
formats was taken low mean score (1.01) between all items of nursing
documentation quality. The total mean of nursing documentation quality items was
(11.44).
The majority of total studied samples resulted in average level of continuity of
patient care (80%)
Regarding the mean of continuity of patient care, nursing intervention was taken
high mean score between all items of continuity of patient care (22.5).followed by,
vital signs were taken second high mean score after nursing intervention (16).
Finally, medication order was taken low mean score between all items of
continuity of patient care (5.80). The total mean of continuity of patient care items
is (14.6).
There was highly statistically significant positive correlation between quality of
nursing documentation and continuity of patient care (r=0.434 -p value=0.001).
Recommendations:
Workshops for nursing staff about the importance of nursing documentation and
documentation standards, principles should be conducted .
Nurses should be encouraged to comply with standard of nursing documentation at
intensive care units.
Nursing documentation policies should be designed and applied to guide nurse‟s
performance.
Continuous supervision of nursing documentation through regular and periodic
auditing is suggested, with constructive feedback, as well as disciplinary actions
for defaulters and rewards for good achievers.
Hospital administration should address the barriers of adequate nursing
documentation.
Further research is proposed to assess the impact of on-the-job training and
application of electronic health records on nurses‟ practices in documentation.
Replication of the study on large sample size and different settings.