The Quality of Clinical Documentation of Patients Admitted to an Iranian Teaching Hospital:A Two-Year Impact of Clinical Governance

Background and Objective: One basic and fundamental source of information in health care is the patient record, of which nursing documentation is a part. Despite continuous and consistent advice from quality improvement programs and professional bodies over several years, achieving and maintaining good standards of clinical documentation is still a problem in the health profession. In Iran, implementation of clinical governance was approved in 2006. As the implementation of health policies in Iran is centralized and there is no especial difference among provinces, this research sought to determine the effect of clinical governance on improving nursing documentation in Kerman, Iran.

Material and Methods: This was a quasi-experimental study conducted in an instructional hospital in Kerman. Documentation of medical records by nurses in the first quarter of 2010 and the fourth quarter of 2012 were assessed. Random stratified sampling was used and 330 records were chosen at random. A researcher made checklist was used to assess the documentation's structure and content. Descriptive statistics and analytical statistics were used to analyze the data. SPSS version 16 was used to analyze the data.

Results: There were no differences between nurse's demographic data before and after two years (P>0.05) except attendance in training workshop (P < 0.05). The nursing documentation score improved more structurally than contently after two-year clinical governance implementation (P < 0.05).

Conclusion: Although some efforts were made to improve nursing documentation by implementing a clinical governance program, these were not sufficient and more attempts are needed.