A nursing audit on charting done by nurses in one hospital in Cavite.
Date of Completion
1995
Document Type
Thesis
Degree Name
Bachelor of Science in Nursing
Keywords
Nursing Administration, Nurses
Abstract
The study sought to determine if there is a significant difference in the compliance in charting among the different areas in the hospital, namely: Surgery, Pediatrics, Obstetrics, and Medicine. There is a significant difference in the compliance in charting in relation to the different aspects of Nursing Audit. Under Formal criterion: laboratory results attached according to dates and current sequence got the highest frequency of yes tally. Under Doctor's Orders: Doctor's orders are written in generic name; special procedures/referrals noted and accomplished within the shift; emergency/STAT orders are carried out, signed timed, charted within half an hour; and orders carried out, transcribed, dated, timed, and signed within one hour, obtained the highest frequency. And under Nurses' Notes: admission notes are legible; charting medications on their generics; all entries are timed and signed legibly; admission notes are relevant; every unusual observations are properly noted; and admission notes are complete, obtained the highest frequency. There is a significant difference in the compliance in charting in the different areas in the hospital: Surgery, Pediatrics, Obstetrics, and Medicine. Under Formal criterion: correct sequence; all sheets have appropriate headings-dated; and recording of temperature, pulse rate, and respiratory rate (TPR) complete and recorded every 4 hours. And under Nurses' Notes: patients response to medications and treatments are noted/charted and unusual observations are properly noted. The null hypothesis was rejected because there is a significant difference in the compliance in charting the different areas in the hospital: Surgery, Pediatrics, Obstetrics, and Medicine. Under Formal criterion: correct sequence: all sheets have appropriate heading-dated; and recording of temperature, pulse rate, and respiratory rate (TPR) complete and recorded every 4 hours. And under Nurses' Notes: patients response to medications and treatments are noted/charted and unusual observations are properly noted.
APA Citation
Buatis, R., Hiwatig, A., Lontoc, R. R., & Pagkalinawan, R. (1995). A nursing audit on charting done by nurses in one hospital in Cavite. [Bachelor's thesis, De La Salle Medical and Health Sciences Institute]. GreenPrints. https://greenprints.dlshsi.edu.ph/bsn/960/