IMPLEMENTATION OF PEDIATRIC NURSING DOCUMENTATION QUALITY AUDIT: A SCOPING REVIEW

Abstrak

Background​ : In clinical practice, documentation of accurate nursing​ is essential for nurses to provide a good quality service.​ Inadequate documentation of nursing care can cause errors in interpretation that potentially threaten the safety of patients. Problems in nursing documentation poses more risk​ in pediatrics patients because of limitations in communication to convey complaints and obstacles they perceived.​ Special nursing documentation in child care room is required to ensure the safety and quality of care provided​ to the patients. The aim is to identify, assess, and map evidence regarding the implementation of documentation quality audits in improving the quality of pediatric nursing documentation. Objective: To identify, assess, and map evidence regarding the implementation of documentation quality audits in improving the quality of pediatric nursing documentation. Methods: A systematic search was conducted by identifying all relevant publications, in relevant bibliographic databases namely PubMed, EBSCO, and Sciencedirect. Relevant articles published in English from 2020 to 2024 were included. Six articles were included in the analysis. Results; Based on this review, the implementation of pediatric nursing documentation quality audit includes interventions of pediatric essential clinical data collection implementation can improve the efficiency and quality of documentation, audits can improve the utilization of pain measurement tools & identify good and suboptimal nutrition practices, management of children with gastroenteritis, transition from hospital to home, pediatric nursing clinical decision support system for hyperthermia can improve the quality of nursing records. Conclusion: the importance of various aspects in improving the quality of children's health care as well as the integration and automation of nursing information systems are essential to improve the accuracy and completeness of nursing records, which overall support the efficiency and quality of children's health care.