Quality improvement in clinical documentation: does clinical governance work?

摘要

Introduction: The quality of nursing documentation is still a challenge in the nursing profession and, thus, in the health care industry. One major quality improvement program is clinical governance, whose mission is to continuously improve the quality of patient care and overcome service quality problems. The aim of this study was to identify whether clinical governance improves the quality of nursing documentation. Methods: A quasi-experimental method was used to show nursing documentation quality improvement after a 2-year clinical governance implementation. Two hundred twenty random nursing documents were assessed structurally and by content using a valid and reliable researcher made checklist. Results: There were no differences between a nurse's demographic data before and after 2 years (P>0.05) and the nursing documentation score did not improve after a 2-year clinical governance program. Conclusion: Although some efforts were made to improve nursing documentation through clinical governance, these were not sufficient and more attempts are needed.