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   فريق العمل المنفذ والمتابع للمشروعProject  Team

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   فريق العمل المنفذ والمتابع للمشروعProject  Team

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Aim of the project is to:

Improve quality of nursing documentation in psychiatric hospital and Al Amal Hospital in Jeddah city.

Objectives of the project are to:

1. Establish a well-organized and reliable nursing documentation that can help promote the quality of patient care.

2. Improve the Nurse–Patient Relationship.

3. Educate  the nurses about the important details related to the Mental Status Examination.

4. Select the appropriate types of  nursing documentation..

5. Enhance  communication with all members of the treatment team to establish continuity of care..

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                                                  Introduction

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                                                  Introduction

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Nursing documentation facilitates continuity of care and patient safety Lack of communication between healthcare providers is related to errors and adverse events. Defects are recognized in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry (Instefjord etal., 2014). Documentation defined as  anything written or electronically generated that defines the condition of the patient or the care  provided to that patient (Calleja etal.,2012). While, Abbas. (2016) defined documentation as any printed or written record of activities. The nursing care plan it considered as a away of documentation which is summaries the plan of action that will be applied during nursing care to patients and it is reflecting the needs and goals of the patient.

Based on  in the  observation during the supervisory visits of the nursing administration in Jeddah region the nurses in psychiatric hospital in Jeddah city, are using narrative nursing notes to document their care, we noted that there writing were not unified some of them are  using English language and the other using  Arabic language, they also do not use terminology related to mental illness, in addition, there is no nursing assessment of the patient's mental status, this did not clarify the tasks provided by the nurses and how the nurses solve the patient's problems, this may impact negatively on  the communication between nurses, patients, and other team members. The nurses at Al Amal Hospital are using the English language when they documented nursing care, but they do not use terminology related to mental illness and do not conduct the nursing assessment of the patient's mental status.

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                                                Project phases

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                                                Project phases

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The training program that was held at  Al  Amal and Psychiatric Hospitals.( 25) nurses from Al Amal hospital and( 26) nurses from psychiatric hospital that are working in the departments selected for the implementation of the pilot study were trained about Mental Status Examination skills. 

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The training program that was held at  Al  Amal and Psychiatric Hospitals.( 25) nurses from Al Amal hospital and( 26) nurses from psychiatric hospital that are working in the departments selected for the implementation of the pilot study were trained about Mental Status Examination skills. 

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                                               Recommendations

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                                               Recommendations

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1.   Implementation of Mental Status Examination forms in Psychiatric and Alaml Hospitals

2.   Train all  the nurses in Al Amal and Psychiatric hospitals about the forms

3.   Follow-up documentation Implementation process by the department of quality and nursing education in  the two hospitals

4.   Transfer the Mental Status Examination forms  to  Electronic Information Systems.