Focus Charting Nursing Documentation in the In-patient Departments, Lampang Hospital

Abstract

Focus charting is a type of documentation that is based on the nursing process of assessment, planning, implementation and evaluation to concentrate on a particular issue and address it. The Data, Action and Response approach (DAR) is used in this method of charting and is meant to keep the information concise. Charting is an integral part of nursing. Nurses are responsible for documenting all care and changes in the patient’s condition. The objective of this study was to compare the nursing documen-tation scores and nurses’ satisfaction between the original narrative nursing documentation and the focus charting nursing documentation. It was conducted as a quasi-experimental research, using interrupted time series design, during the years 2013-2015, covering 693 nursing documentations per year and 147 nurses in 39 in-patient departments of Lampang Hospital. The scoring instrument for nursing documenta-tion was based on the criteria of the Bureau of Nursing, Ministry of Public Health and the National Health Security Office of Thailand. The data were analyzed by descriptive statistics and t-test. It was found that the scores of focus charting nursing documentation in 2015 were significantly higher than those of the 2013 narrative nursing documentation in the areas of Assessment, Planning, Implementation, Evaluation and Medication (p<0.01). Moreover, the number of the in-patient departments passing the criteria and nurses’ satisfaction of documentation had increased. The findings of this study confirm that applying the focus charting approach had significantly improved the nursing documentation and, therefore, should be more widely implemented.