Document Type : Original Article
Authors
1 Shahrekord University of Medical Sciences, Shahrekord, Iran.
2 Iranian Research Center on Healthy Aging, Sabzevar University of Medical Sciences, Sabzevar, Iran
Abstract
Background: One of the major concerns of nurses in all countries of the world is nursing documentation. 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 and uses the conventional content analysis approach. The participants in this study were clinical nurses working in one of the universities of medical sciences 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, as well as observation of nurses' report writing performance.
Results: Interviews with the participants were conducted during 9 months (May 2023 to December 2023). 38 interviews were conducted face-to-face. The duration of the interviews was 15-45 minutes, and an average of 30 minutes. 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, self–centered 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
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