RESUMO
Background Nursing progress notes in Selayang Hospital was found to be non-compliance according to Malaysian local accreditation bodies in 2007. In June 2008, Department of Dermatology were assigned with dedicated nurses. Aim To look into the quality of monitoring of Dermatology patients by nurses which is reflected by the content in nursing progress notes before and after being taught by Dermatology nurses. Methodology A retrospective comparative audit of the quality of nursing progress notes in ward patients that required Dermatology management in May 2006 and May 2009 in Selayang Hospital was performed. Parameters assessed include the patient’s general condition, skin symptoms and signs, alerting doctor whenever there is change in skin condition and nursing intervention. Exclusion criteria include documentation by the same nurse at different times. Results 325 nursing progress notes were reviewed in 2006 and also in 2009. 70% of nurses described the symptoms and signs of skin lesions at that point of time in 2009 whereas only 5% of nurses did that in 2006. Documentation of intervention performed for the current skin lesions in 2009 and 2006 were 81% and 48% respectively. Only 4% of nurses informed doctor on finding a change in skin condition 2006 as compared to 71% in 2009. Conclusion The audit shows that designated skin nurses can assist the ward nurses to improve their clinical documentation.