الفهرس 
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Abstract
Quality nursing documentation promotes structured and sufficient communication between health care workers so that they are better informed of patients’ conditions and the care planned and provided to them. It ensures the information contained in nursing records can be used as valid evidence for attempts to show what happens in the nursing process and informed clinical decision making. The primary function of nursing documentation is as a communication tool to facilitate individuality and continuity of care and safety of patients. Nursing documentation also serves other purposes such as quality assurance, legal instrument, health planning and research.
The present study aimed to evaluate the effect of internal quality management system on quality of recording system among nursing personal and examining the relationship between the quality of recording system before and after application of internal quality system.
The present study was conducted at Benha Children Hospital Special in neonatal care unit and in pediatric intensive care unit.
Data for this study were collected by using two tools
1) Auditing format :(Appendix I):
An auditing technique was used to review the patient nursing record. This sheet was depending on applier (Safan, 2008), (Higazee, 1998). It consists of two parts:-
A. Retrospective audits of patient records in the last four months before implementing internal quality system, total no. (142 records) used for assessing the quality of recording system before application of internal quality system.
B. Concurrent audits of patient records after implementing quality program during time of study total no. (162 records) used for assessing the quality of recording system after application of internal quality system.
2) Nursing documentation questionnaire :(Appendix II ):
It consists of all staff nurses working in selected units during time of data collection: (56 nurses) used for assessing nurses’ information about recording system.
The study has generated the following findings:
There was significance improvement in nursing documentation of demographic data, initial assessment sheet, vital sign chart, nurses’ notes, blood transfusion, and general criteria of documentation after implementation of internal quality system except medication chart, fluid balance chart.
There was significance improvement in nursing documentation performance at pediatric intensive care unit than premature units after implementation of internal quality system.
There was highly statistically significance improvement in evaluating level of nursing documentation forms of initial assessment sheet, vital signs chart, blood transfusion, and nurses note sheet after implementation of quality system except demographic data, fluid balance chart, and medication chart.
The majority of nurses confirmed the presence of quality committee and training courses in spite of this it does not provide forms of admission sheet and discharge sheet, nursing not aware problems of the nursing documentation and standards are not applied.
The majority of nurses have a desire to enter the electronic system in the nursing documentation.
Based on the results of the study, the following was recommended:
- At practice level
- The Quality Committee should revise type of nursing formats. The update formats should include patients’ needs and nursing care plan records.
- Quality Committee should provide training programs for nursing documentation with simple and easy way.
- Nursing staff must be continuously motivated to provide quality nursing care through accurate documentation by giving them incentives, faire treatment, flexible scheduling and paid educational leaves.
- Unit’s managers and their charges must provide sufficient supervision, guidance, and pursue correction to enable nurses to become accountable for the quality of their nursing documentation.
- At educational level
- Diploma nursing program’s curricula should include theoretical and practical part of nursing documentation to emphasize knowledge and application of nursing care plans.
- At research level
Further study is needed to assess the possibility of using computer- based system in hospital setting to decreased waste time in nursing documentation.