The Effects of a Nursing Documentation Program by using Focus Charting in the Inpatient Department of Sam Roi Yot Hospital, Prachuap Khiri Khan Province

Abstract

This study aimed to compare professional nurses’ knowledge of nursing documentation using the focus charting format in the inpatient department of Sam Roi Yot Hospital, Prachuap Khiri Khan Province, before and after program implementation. It also aimed to compare the quality of nursing documentation using the focus charting format before and after the implementation of the program. The sample consisted of 22 professional nurses selected through purposive sampling and 302 inpatient medical records selected using stratified random sampling. The research instruments included a focus charting nursing documentation program, an interview guide regarding nursing documentation practices, a knowledge test on focus charting documentation, and a quality assessment tool for nursing documentation using the focus charting format. Data were analyzed using descriptive statistics, Wilcoxon signed – rank test and paired t-tests. Qualitative data were analyzed using content analysis. The results revealed that:

1. After program implementation, professional nurses’ knowledge of nursing documentation using the focus charting format was significantly higher than before the implementation.

2. After program implementation, the quality of nursing documentation using the focus charting format was significantly higher than before the implementation.

Therefore, improving the quality of nursing documentation using the focus charting format should involve continuous knowledge enhancement, collaborative coaching, and regular evaluation of nursing documentation to ensure ongoing professional development among nurses.