An audit of discharged patient files at hospitals specialising in the management of tuberculosis

Werely, Volene Joy (Stellenbosch : University of Stellenbosch, 2011-03)

Thesis (MCur)--University of Stellenbosch, 2011.

Thesis

ENGLISH ABSTRACT: Background: In her clinical practice as nursing manager the researcher was concerned about incomplete and inaccurate documentation of patients diagnosed with tuberculosis (TB) which were compromising the management of these patients. The primary care nurses endorsed these concerns. Goals and Objective: The goal of this study was to audit nursing documentation according to the phases of the nursing process and the discharge planning of patients diagnosed with TB discharged from TB hospitals in the Western Cape. The objectives for the study were to determine whether the patients were adequately assessed and diagnosed, whether nursing care plans were formulated based on the assessment and whether they were implemented and evaluated according to the nursing process - including the discharged planning. Ethics approval was obtained from the Committee of Human Research Science at Stellenbosch University and permission was also obtained from the respective institutions. Methodology: A descriptive design with a quantitative approach was applied for the purpose of this study. The total population for the study was N=1768. A systematic random sample of 12% from each hospital was drawn: n=214, hospital A (n=142) and hospital B (n=72). Criteria included:  all adult patients older than 18 years  patients who were discharged between 01 January 2007 and 31st December 2007  all discharged patients from the two hospitals specializing in patients diagnosed with TB. Instrumentation: An audit instrument based on the objectives of the study was approved as the data collection tool. Guided by the proposed study a 10% (n=21) of the number of discharged patient files were drawn for the purpose of a pilot study. Reliability and validity was ensured through the use of experts in the field of nursing, research methodology and statistics. A pilot study was also conducted to support the reliability and validity of the study. Data collection: The researcher collected the data personally with the support of five trained field workers who only assisted at hospital B and was reluctant to assist at the second hospital. Data analysis: Data was analysed with the support of a statistician and expressed in frequencies and tables. Results: All phases of the nursing process showed a low compliance. Results showed that only n=90(42%) of the registered professional nurses checked and signed the initial assessment, furthermore only n=53(34%) showed that a recording was made of all referral documentation to the patient’s follow-up clinic. Recommendations: Recommendations based on the scientific evidence obtained from the study include the implementation of a quality assurance programme namely standardisation, auditing, case management of patients, education and training, rewarding of staff and further research. Conclusion: In conclusion guided by the research question “Are the audited discharged patient files at hospitals specialising in the management of patients with TB in the WCDoH compliant?” The researcher concludes that the discharged patient files are not compliant.

AFRIKAANSE OPSOMMING: Agtergrond: In haar kliniese praktyk as verpleegbestuurder is die navorser besorgd oor die onvolledige en onakkurate dokumentasie van pasiënte wat met tuberkulose (TB) gediagnoseer is en wat dus die versorging van hierdie pasiënte in gevaar stel. Hierdie besorgdhede is deur die primêre sorg verpleegsters bevestig. Doel en Doelwitte: Die doel van die studie is om die verpleegdokumente te ouditeer volgens die fases van die vepleegproses, asook die ontslagbeplanning van die pasiënte gediagnoseer met TB van die hospitale in die Wes-Kaap. Die doelwitte is om te bepaal of die pasiënte korrek geassesseer en gediagnoseer is en of verpleegsorgplanne opgestel is, wat gebaseer is op die assessering en versorgingsplanne wat geïmplementeer en geëvalueer is volgens die verpleegproses, insluitende die ontslagbeplanning. Etiese goedgekeuring is toegestaan deur die Komitee vir Menslike Navorsingswetenskap van die Universiteit van Stellenbosch en toestemming is ook ontvang van die onderskeie instansies. Metodologie: ’n Beskrywende ontwerp met ’n kwantitatiewe benadering is toegepas vir die doel van die studie. Die totale bevolking vir die studie is N=1786. ’n Sistematiese ewekansige geselekteerde steekproef van 12% van elke hospitaal is geneem: n=214, hospitaal A (n=142) en hospitaal B (n=72). Die kriteria sluit in:  alle volwasse pasiënte ouer as 18 jaar  pasiënte wat gedurende die periode 01 Januarie 2007 tot 31 Desember 2007 ontslaan is  alle ontslag pasiënte van die twee hospitale wat spesialiseer in pasiënte wat gediagnoseer is met TB. Instrumentasie: ‘n Ouditinstrument gebaseer op die doelwitte is goedgekeur as die dataversamelingsinstrument. Na aanleiding van die voorgestelde studie is 10% (n=21) van die aantal ontslag pasiëntlêers getrek vir die doel van die loodsondersoek. Betroubaarheid en geldigheid is verseker deur gebruik te maak van deskundiges in die verplegingsveld, die navorsingsmetodologie en statistiek. Die loodsondersoek is ook uitgevoer om die betroubaarhied en geldigheid van die studie te rugsteun. Dataversameling: Die navorser het die data persoonlik gekollekteer met die bystand van vyf opgeleide veldwerkers wat slegs hulp verleen het by hospital B en wat teësinnig was om hulp te verleen by die tweede hospitaal. Data-analise: Data is geanaliseer met die hulp van ’n statistikus en is uitgedruk in frekwensies en tabelle. Resultate: Alle fases van die verpleegproses het nie voldoen aan die vereistes nie. Resultate dui daarop dat slegs n=90 (42%) van die geregistreerde professionele verpleegsters die aanvanklike assessering nagegaan en onderteken het, vervolgens het slegs n=53 (34%) getoon dat ’n opname gemaak was van alle verwysde dokumentasie van die pasiënt se opvolgbesoek aan die kliniek. Aanbevelings: Aanbevelings is gebaseer op die wetenskaplike bewys wat verkry is van die studie vir die implementering van ’n gehalte versekeringsprogram, naamlik standardisering, ouditering, gevallebestuur van pasiente, opvoeding en opleiding, erkenning aan die personeel, en voortgesette navorsing. Samevatting: Ter afsluiting gelei deur die navorsering’s vraag nl. “Is die geouditeerde verpleegdokumente in hospitale wat spesialiseer in die bestuur van pasiente gediagnoseer met TB in die Weskaap se Department van Gesondheid bygehou?” Die navorser bevestig dat die verpleegdokumente nie bygehou was nie.

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