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The current status of nurses’ notes of medical record in Nam Dinh | Journal of Nursing Science
The current status of nurses’ notes of medical record in Nam Dinh

HAND - HEART - HEAD - HONOR
Original Articles | Vol. 1 No. 1 (2018)
Journal of Nursing Science, Vol. 1 No. 1 (2018) Original Articles

The current status of nurses’ notes of medical record in Nam Dinh

Published 2018-03-14
Thu Hien Tran
Nam Dinh University of Nursing
Thi La Vu
Nam Dinh University of Nursing
Manh Dung Nguyen
Nam Dinh University of Nursing
Thi Thanh Huong Nguyen
Nam Dinh University of Nursing
Thi Thu Huyen Dinh
Nam Dinh University of Nursing
PDF (Tiếng Việt) Download: 955 View: 1634

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Tran, T. H., Vu, T. L., Nguyen, M. D., Nguyen, T. T. H., & Dinh, T. T. H. (2018). The current status of nurses’ notes of medical record in Nam Dinh. Journal of Nursing Science, 1(1), 77–83. Retrieved from https://jns.vn/index.php/journal/article/view/82
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Abstract

Object: The research conducted from March to September, 2015. The combination of qualitative and quantitative research methods was used in this study. The researcher randomly selected and reviewed 170 medical recordsto describe the current status of nurses’ notes. In addition, we selected 9 nurses at General Medicine. The setting was Nam Dinh province General Hospital, Nam Dinh town General Hospital, and My Loc General Hospital.

Results: The results show that the current status of nurses’ notes had many limitations: only 7.1% good; comparied with 29.4% well and 52.9% medium at nurses’ notes with medical records. Nurses had good awareness of the importance of recording; There was a correlation between level of nurse, hospital type, duration of treatment, and status of nurses’ notes (p < 0.05). C

onclusion: Enhancing nursing awareness of importants nurses’ notes with medical records. Conducting research to developt new medical record to support convenienting note and management.

Keywords

record keeping, medical record ghi chép hồ sơ, hồ sơ bệnh án
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Copyright (c) 2018 Journal of Nursing Science

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