The purposes of this research were to analyse the content and to evaluate the quality of nurses’ notes in government and private general hospitals, Bangkok Metropolis. The samples of 500 nurses’ notes were selected by multi-stage sampling techniques. The instrument used in this study was an observable scale developed by the researcher. An observable scale was tested for content validity and its reliability was equal to 0.81. Statistical procedure used for data analysis were percentage, Chi-Square, t-test, F-test and Scheffe’s method. The results of the study were as follow. 1. The first three of content appeared in nurses’ notes in each categories were as follow:- Basic needs: Rest and sleep, Nutrition and Diet therapy, and Vital signs. Nursing Implementation: Therapeutic care, Patients’ problems-solving, and Follow-up. Patient’s behavior: Patients’ behavior corresponding with medical diagnosis, Patients’ physical assessment, and patients’ mental and emotional assessment. 2. The proportions of content in nurses’ notes in private hospitals were higher than the content of nurses’ notes in government hospitals. The summary of finding was as follow. 2.1 Basic needs: There was a statistically significant difference at .01 level in the items of Rest and sleep, Nutrition and Diet therapy, Vital signs, Urination, Elimination, Personal care, Water and fluid balance, Exercise and rehabilitation, Relationship with family and nurses. There was a statistically significant difference at .05 level in the items of Physical movement, Prevention of complication and infections. 2.2 Nursing Implementation: There was a statistically significant difference at .01 level in the items of Therapeutic care, Patients’ problem-solving, and Medical report. 2.3 Patient’s behavior: There was a statistically significant difference at .01 level in the items of Patients’ physical assessment, and Disorder of words or behavior. There was a statistically significant difference at .05 level in the item of Patients’ behavior corresponding with their illness.
3. The proportions of content in nurses’ notes between Medical department, Surgical department, Obstetric and Gynecological department, Pediatric department and Eye-Ear-Nose-Throat department. The summary of finding was as follow. 3.1 Basic needs: There was a statistically significant difference at .01 level in the items of Urination, and Self-care teaching. There was a statistically significant difference at .05 level in the items of Restand sleep, Water and fluid balance. 3.2 Nursing Implementation: There was a statistically significant difference at .01 level in the items of Patients’ problem-solving, and Evaluating of nursing care. There was a statistically significant difference at .05 level in item of Follow-up. 3.3 Patient’s behavior: There was a statistically significant difference at .01 level in all five items of Patient’s behavior. The Patient’s behavior was Patients’ behavior corresponding with medical diagnosis, Patients’ physical assessment, Patients’ mental and emotional assessment, Disorder of words or behavior, and Patients’ opinion concerning their illness and therapeutic care. 4. Evaluating the quality of nurses’ notes between the government and private hospitals. The summary of finding was as follow. 4.1 Coverage: There was a statistically significant difference at .05 level in all three items of coverage. The Coverage was Basic needs, Nursing Implementation and Patient’s behavior. The mean score of private hospitals was higher than the government hospitals. 4.2 Clarity: There was a statistically significant difference at .05 level in the item of Audit Facilitating. There was a statistically significant difference at .01 level in the item of Continuity. The mean score of private hospitals was higher than the government hospitals. There was a statistically significant difference at .05 level in the item of Usage in language. 5. Evaluating the quality of nurses’ notes between Medical department, Surgical department, Obstetric and Gynecological department, Pediatric department and Eye-Ear-Nose-Throat department. The summary of finding was as follow. 5.1 Coverage: There was a statistically significant difference at .01 level in the item of Nursing Implementation between Obstetric and Gynecological department and Medical department. There was no statistically significant at .05 level in the items of Basic needs, and Patient’s behavior among all five departments. 5.2 Clarity: There was a statistically significant difference at .01 level in the item of Continuity between Surgical department and Obstetric and Gynecological department. And also between Obstetric and Gynecological department and Eye-Ear-Nose-Throat department. There was no statistically significant difference at .05 level in the items of Usage in language, and Audit Facilitating among all five departments.
