11. THỰC TRẠNG GHI CHÉP HỒ SƠ ĐIỀU DƯỠNG NỘI KHOA VÀ MỘT SỐ YẾU TỐ LIÊN QUAN TẠI BỆNH VIỆN ĐA KHOA TÂM ANH HÀ NỘI NĂM 2022- 2023

Abstract

Objective: Describe the status of compliance with medical nursing records and analyze some factors related to the quality of nursing records.

Subjects and research methods: The Cross-sectional description study of 240 medical nursing recordeds at Tam Anh General Hospital from 12/2022 to 04/2023.

Results: The current state of medical nursing records meeting 85% total nursing record score is 95.8%; those meeting 100% total nursing record score is 17.9%. The rate of successful recording of the patient’s initial assessment form (87.9%), monitoring the patient’s progress and care plan (54.2%), the fall risk assessment sheet (80%), the health advice and education sheet (47.9%), administration and disclosure of medication sheet for patients (73.8%), monitoring sheet of consumables use (94.2%). There is a statistically significant difference between the length of hospital stay, the quality of health education consultation notes, and the quality of nursing records recording between internal clinical departments (P<0.05).

Conclusion: Internal medical nursing records have 85% to < 100% the total score of nursing records accounts for 95.8%. Priority should be given to monitoring that focuses on record-keeping deficiencies and improves the form to enhance the quality of nursing record-keeping further.