Studying nurse s care history recording

Abstract

Background: In Mongolia, before 2013, there was no ofÏcial nursing history to record nursing care provided to patients. In 2013 review by Finnish researcher Kaija Saranto et al., who analyzed 143 research articles, they noted the need for standardized terminology for nursing histories, and found it important to have a common understanding of how to record daily activities and patient safety information. In a study conducted by researcher B.Azjargal et al. in 2017, it was considered that the complete implementation of nursing history evaluation according to Gordan indicators is moderate. In a 2018 study conducted by researcher D. Ariunaa et al, when evaluating the nursing history of acute heart attack patients, 80.5% of 36 patients with acute heart attack had a nursing history documented. It has been 10 years since we implemented nursing history; therefore, there is a need to evaluate nursing history. Aim: To evaluate the nursing record keeping and study the factors affecting it. Materials and Methods: The study was conducted using a qualitative research method using a quality research documents, and 4 types of 120 nursing histories’ documents conducted in the surgical and internal medicine departments of the First Central General Hospital, General Hospital of Central province, Khovd, Sukhbaatar and Umnugobi Provinces’ regional diagnostic and treatment centers were analyzed. In the analysis, an evaluation sheet with 33 questions was developed based on the instructions for keeping nursing history approved by the order of the Minister of Health No. 611 of 2019. Statistical processing of the research the data of the research on the nursing history of the health institution included in the study were processed using the “SPSS-22” software. According to the purpose and objectives of the study, hypotheses were made and tested by appropriate statistical methods (chi-square, p, ANOVA), and if the p value was less than 0.05, the difference was considered statistically probable. Results: On average, nurses spend 22.9 minutes in the internal medicine department and 25.4 minutes in the surgical department for taking nursing history. In the research of nursing history keeping by documentary method, 70% (84) (p=0.0001) did not keep the patient’s vital signs sheet, 32.5% (39) (p=0.0001) did not fully understand and fill in the parameters to evaluate the patient’s condition, and it differs between hospitals. When looking at nursing record keeping by hospital, patients’ vital signs sheets are incomplete or not kept at the First Central Hospital 15% (6), Sukhbaatar province General Hospital 100% (20), Hovd Regional Diagnostic and Treatment Center 100% (20), Umnogobi Regional Diagnostic Center treatment center 100% (20), Central Province General Hospital 90% (18), (p=0.0001), Sukhbaatar Province General Hospital 55% (11), Khovd Province Regional Diagnostic and Treatment Center 60 % (12), Umnogobi province Regional Diagnostic and Treatment Center was 45% (9), and the Central Province General hospital was 35% (7), (p=0.0001). 64.2% (77) (p=0.0001) did not keep the pain and fluid balance monitoring sheet and did not do it. Considering each province, Sukhbaatar General Hospital 100.0% (20), Khovd Province Regional Diagnostic and Treatment Center 100% (20), Umnogobi Province Regional diagnostic and treatment center was 95.0% (19), Central province General Hospital was 90.0% (18), (p=0.0001). Conclusion: Most of the nursing records were not kept on the patients’ vital signs sheet, the patients’ condition assessment parameters were not fully understood and completed, the pain and fluid balance control sheets were not kept or insufÏciently kept, and it differed between hospitals.