Developing a manual for documenting patient care

Quality patient care is frequently measured through analysis of the communication systems prevalent in nursing units. Accreditation agencies frequently use nursing records and documentation of nursing activities as objective measures of quality of patient care. Moreover, proper documentation tools are essential to help nurses in better communication and hence, improving their nursing care. The present study was designed with the aim to assess the availability of different types of reports and records used in the inpatient units at the Alexandria Main University Hospital and the pattern of their documentation, assess nurses' knowledge and learning needs for documentation and develop a manual to improve nursing communication system. The manual will be a tangible written document available for nurses and as a way to conceptualize and present program contents that will meet the goal and captivate the interest of the diverse learning group, instead of a single workshop as a teaching strategy that would do little to influence long term learning and achieve a sustained ciiange in behavior. The study included two general medical and two general surgical units, all nurses assigned to these four units who were available at the time of the study (50 nurses) and a representative sample of medical records (40 records) of patients admitted to the study units during the period of data collection were reviewed. The study revealed that some nursing records and reports are totally omitted and most of the general criteria of documentation were not met by the nursing staff with a negative effect on quality of recording and hence the quality of nursing care provided. Moreover, assessment of the nurses' knowledge and learning needs regarding the communication process and the' documentation system showed a dire need for developing a manual to meet their learning needs and upgrade their communication skills for improving quality of care.Example: Alexandria universit