Abstract

Since 2009, with the approval of the health service of An Giang province, a new modified set of clinical nursing care have implemented at 9 clinical wards in An Giang general hospital. The new modified set includes 4 sheets: physician's order sheet, nurse report sheet, patient monitoring sheet and nursing care plan sheet. This set is used to note the progression of the patient's health condition and record all kinds of nursing interventions. The main feature of this set is to have a nursing care plan sheet in which nurses could write all the actively care plans for patients and help to limit the repeated several times for some information.   To evaluate the effectiveness of the new modified set, we randomly selected and reviewed 69 medical records of patients admitted to An Giang hospital in September 2011. The aim of this review was to describe the current status of nurses' notes and to propose the solutions how to improve the quality of patient cares through this new modified set. During the implementation, we have found some advantages of the new modified set as followed: - The physician's order sheet is not only to help nurses to save time but also to help the patient Safety in using of medication. - The nurse report sheet including 2 signs: identifying (N) and checking (K) which help doctors and/or nurses to monitor the recently appearing problems of the patients. - The patient monitoring sheet with the sign of “special attention” was used to note the information needed to monitor the patient during hospitalization. - The nursing care plan sheet helps nurses taking care the patients according to plan, avoid omission of nursing interventions for patient's progression and helps to fulfill the actively function of nurses. At the initial stage of the year 2009, nurses hesifated to use the care plan sheet because of wasting their time and their energy. From October 2011 to date, with the support of the research team who trained nurses how to take notes, how to write the guidelines for nursing care plan according to specialties, and launched the emulation movement “to score the document written by nurses” which boost significant inerease in the rate of medical records with-fulfilled information.