The Related Factors with to Quality of Nursing Documentation of Patients Diagnosed with Poisoning in the Emergency Department: A Cross-Sectional Study

One of the most important and controversial roles of nurses is documentation, which is especially of great importance in the emergency department. Patients with a diagnosis of poisoning are one of the most common and challenging emergency department patients, which involve many ethical and legal issues. This research aimed to determine the related factors to the quality of nursing documentation of patients diagnosed with poisoning in the emergency department.

The present research is a cross-sectional study. Sampling among 1402 emergency cases (384 cases) in the first half of the year was done by simple random sampling. In order to collect data, the nursing documentation quality checklist was used with two dimensions’ report writing and medication administration.

The evaluation of the patients’ documents showed that the average and standard deviation of the age of the patients were 29.96 ± 9.93 years and most of the patients (60.2%) were women. The mean and standard deviation of the documentation quality were 8.75 ± 6.82 from the range of -48 to 48. The quality of nursing documentation had a statistically significant relationship with some characteristics of patients, including age, education, history of alcohol consumption, and history of admission to the emergency room.

Based on the findings of the study and considering the importance of nurse documentation as the most important document in judicial authorities, it is necessary to take basic steps to improve the documentation knowledge of nurses in the emergency department and specifically for patients diagnosed with poisoning. It is also necessary to pay more attention to elderly, illiterate patients and those with alcohol consumption.