Assessment of Compliance with Nursing Care Documentation for Patients with Acute Coronary Syndrome Using the Clinical
Setareh Homami1, Farshad Zinvand-Moghaddam, Maryam Rassouli
1Author Affiliations: Research Center for Public Health Sciences and Technologies, Semnan University of Medical Sciences, Semnan, Iran (Dr Homami); and Department of Public Health, Semnan University of Medical Sciences, Semnan, Iran (Dr Homami); Student Research Committee, Nursing School, Semnan University of Medical Sciences, Semnan, Iran (Mr Zinvand-Moghaddam); Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (Dr Rassouli); and School of Nursing, College of Health Sciences, University of Nizwa, Nizwa, Sultanate of Oman (Dr Rassouli); Department of Health Information Technology, Khomein University of Medical Sciences, Khomein, Iran (Dr Valinejadi); Health in Emergencies and Disasters Group, Faculty of Allied Medical Sciences, Qom University of Medical Sciences, Qom, Iran (Dr Ebrahimian); and Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran (Dr Ebrahimian).
Abstract:
Nursing documentation based on the Clinical Care Classification (CCC) system has positive results and is an excellent model to follow. This study investigated the compliance of nursing care documentation of acute coronary syndrome (ACS) patients with the CCC system. In a directed content analysis study based on the CCC system, the degree of compliance with nursing care records in patients with ACS was assessed. In the first phase, the files of all patients (108 cases) with ACS admitted to the emergency ward for 18 months were included. In the study's second phase, by purposeful sampling, verbal reports of nursing care during shift handovers were analyzed. Several new meaning units emerged in the analysis of patients' records. The most widely used new meaning unit was the patient referral method, and the next item was the site of the IV line. The overall compatibility between our findings and CCC was 27.3% in the cardiac component. The compatibility in nursing diagnosis, nursing interventions, and evaluation of nursing interventions was 25%, 33.3%, and 25%, respectively. While our study revealed a low degree of compatibility of nursing diagnosis, interventions, and evaluation with the cardiac component of the CCC system, it also highlighted the potential for improvement.
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