THE CURRENT STATUS OF NURSES’ NOTES OF MEDICAL RECORD IN NAM DINH

Abstract

Objective: The research conducted from March to September, 2015. The combina-tion of qualitative and quantitative research methods was used in this study. The resear-cher randomly selected and reviewed 170 medical recordsto describe the current sta-tus 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 re-sults show that the current status of nurses’ notes had many limitations: only 7.1% good; comparied with 29.4% well and 52.9% me-dium at nurses’ notes with medical records. Nurses had good awareness of the impor-tance of recording; There was a correlation between level of nurse, hospital type, dura-tion of treatment, and status of nurses’ notes (p < 0.05). Conclusion: Enhancing nursing awareness of importants nurses’ notes with medical records. Conducting research to developt new medical record to support convenienting note and management.