Document Type : Original Article

Authors

• Mostafa Roshanzadeh ¹
• Ali Taj ²

¹ Shahrekord University of Medical Sciences, Shahrekord, Iran

² Iranian Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Iran

Abstract

Introduction: One of the major concerns of nurses in all countries of the world is nursing documentation. Persistent gaps in nursing documentation, such as incomplete or falsified reports, threaten patient safety and professional accountability, highlighting an urgent need for effective strategies to ensure accurate and ethical reporting. Considering that the documentation of the medical file is an important legal and professional need for nurses, this study was carried out to explain the different reporting methods.
Method: The design of this study is qualitative, which uses the conventional content analysis approach. The participants in this study were clinical nurses working at one of the medical sciences universities who had at least one year of clinical work experience. In-depth, face-to-face semi-structured interviews and open-ended questions were used to collect data, along with observations of nurses’ report writing performance. Interviews with the participants were conducted during 9 months (May 2023 to December 2023). Twenty-three face-to-face interviews were conducted. The average interview time was 45 minutes.
Results: The analysis of the interviews revealed that the nurses employed two methods: positive strategies (regular and principled recording, legality in reporting, and ethical recording) and negative strategies (hiding reality, defensive recording, and fake reporting without action).
Conclusion: Nurses should act based on the job description and related laws and regulations. If nurses pay attention to the reports according to the existing principles and standards, registration errors will be avoided, and they can prevent the evasion of the law and the use of negative strategies that cause a decrease in the quality of care and harm to patients.

Keywords

• Nursing
• Documentation
• Nursing records