عنوان مقاله [English]
نویسندگان [English]چکیده [English]
Background and Aims:Recording and reporting are important tasks of every nurse. Recording medical information in the hospital documentations is, in fact, providing evidence of the activities performed by the medical team at hospital. The purpose of this study is to evaluate the nurses’ compliance documentation principles in Sabzevarhospitals in 2013.
Materials and Methods: This descriptive study was commited on 96 records selected from the hospital general wards in 2013, using random sampling of a list included 37 items. Nurses’ document status was assessed in terms of content and structure. Data were analyzed with version 16 of SPSS software.
Results: The findings of this study showed a61/49% Compliance with documentation principles in three teaching hospitals in Sabzevar. The highest average recorded,was related to the recording of the acute changes (99/87), recording of the follow-up cases (93/85) and the lowest average was about recording of the intake and output (57/18) and recording of the activity and rest situations (50/15).
Conclusion: The study findingsrevealed serious deficiencies in data recordingof nurses’ reports. Accordingly, we need to provide solutions to improve the quality of these reports. It is recommended to provide properly-preparedfunctional instructions on proper way ofreporting to nurses periodically and continually.