Comprehensiveness and completeness of managing of nursing documentation in selected medical institution

This bachelor thesis deals with the topic ``Complexity and completeness of keeping nursing care documentation in a selected medical facility``. The thesis is drafted in the theoretical part and empirical part. The objective of the empirical part of the investigation was to survey the complexity and completeness of keeping nursing care documentation in a selected medical facility. In accordance with the objective, we set two hypotheses. H1: Nurses keep nursing care documentation in accordance with the applicable standard. A H2: Nurses in surgery units keep nursing care documentation more complexly than nurses in internal departments. To collect data we chose the quantitative method of research by means of nursing care audit. The research sample consisted of 60 pieces of nursing care documentation, 30 pieces of documentation in a surgery unit and 30 pieces of documentation in the internal department of the Tábor Hospital, a.s. The overall success rate in the audit ``Complexity of keeping nursing care documentation{\crqq} was 99.73 per cent in the internal department and 91.12 per cent in the surgery department. At the same time, no audit index results have dropped below 76 per cent in the entire set (60 pieces of documentation), and below 53 per cent in partial sets (30 pieces of documentation). H1 hypothesis: Nurses keep nursing care documentation in accordance with the applicable standard, has been, on the grounds of the results obtained, confirmed. The overall success rate of the audit of the nursing care documentation in the internal department was almost by 8.5 per cent higher than that in the surgery department. For that reason, it is possible to make the conclusion that the H2 hypothesis: Nurses in surgery units keep nursing care documentation more complexly than nurses in internal departments, has not been confirmed. In the final discussion, results from the conducted audit in the two departments were summed up and, subsequently compared with literature. Practical use was set in the final part. The results of the bachelor thesis were given at the disposal of the staff nurse of the Tábor Hospital, a.s., to conduct improvement in keeping documentation or to conduct subsequent audits. Last but not least, a local standard for keeping nursing care documentation as the basis for drawing up a new standard in individual departments of the team of nursing care, was drafted and subsequently submitted