مجله کودکان کاسپین

Background: Accurate and complete documentation of nursing records is one of the preconditions of the evidence-based cares and is considered as one of the most important professional tasks in nursing. The aim of the present study was to audit the nursing reports in intubated neonates admitted in neonatal intensive care unit of Ayatollah Rouhani hospital, Babol.

Methods: In this cross-sectional study, 100 nursing reports were randomly selected from the neonatal intensive care unit. Data were collected by a researcher using a checklist which was developed in accordance with the standard and indicators of nursing documentation in national and international reliable sources and then compared after determining the content validity and reliability (observers' agreement coefficient).  Data were analyzed using SPSS20, and statistical methods of Man-Whitney and Kruskal-Wallis were used at a significant level of p<0.05.

Results: The quality of 93%, 1% and 6% of nursing records was good, moderate and poor, respectively. Overall, the quality of nursing records was desirable in terms of content and structure and there was no significant difference in nursing documentation record in dimensions of structure and content according to overtime (P=0.92 and P=0.11), work experience (P=0.61 and P=0.16) and age group (P=0.09 and P=0.76).

Conclusions: The quality of nursing records in neonatal intensive care unit of Ayatollah Rouhani Hospital of Babol has been improved according to the Accreditation of Health Care Centers. In addition, the increase of nurses' knowledge about legal and professional issues has also been effective on improving the quality of the documentation.