Quality of nursing documents in medical-surgical wards of teaching hospitals related to Tabriz University of Medical Sciences

BACKGROUND: The aim of present study was to determine the quality of nursing documents in medical-surgical wards and factors affected this quality. METHODS: In this descriptive study the quality of nurses' documents in medical-surgical wards of teaching hospitals related to Tabriz University of Medical Sciences was assessed. For data gathering, four checklists assessed four parts of nursing documents including: recording nursing report, recording medication treatment, recording vital sign assessment, and recording intake and output (I & O) of fluids were used. The validity of checklists assessed by content validity and the reliability of them calculated with inter-rater reliability. The study sample was including 170 nurses selected with simple random sampling. For each nurse, in four selected parts of documents, three documents were assessed in different times. Finally, in each part of documents 510 documents was assessed. For data analyze descriptive and inferential statistics was used. RESULTS: The average age of nurses were 32.40 ± 5.58 years, 87.65% of them were female and 51.23% of them worked in surgical wards. 70.6% of nursing documents have a moderate quality and 29.4% of them have a good quality. Furthermore, the quality of females' documents were better than males' documents and the quality of surgical nurses' documents were better than medical nurses' documents. CONCLUSION: The quality of nurses' documents in medical-surgical wards of teaching hospitals related to Tabriz University of Medical Sciences was acceptable. However, related to correlation of demographic factors with the quality of nurses' documents further investigation is needed.