Assessing Nurses' Knowledge and Auditing their Practices Regarding Nursing Care Documentation

Nora Hassan

doi:10.21608/pssjn.2018.33187

Abstract

Background: Nursing documentation is essential for quality of care, which facilitates continuity and individuality of care. Aim of the study: The study was aimed at assessing nurses' knowledge and auditing their practices regarding nursing care documentation. Setting: It was carried out in the medical and surgical units of Mansoura University Hospital. Design: using an analytic cross-sectional design. Subjects: Consisted o f 100 staff nurses and 557 nursing care charts. Tools and procedure: were a self-administered questionnaire and an audit sheet. The fieldwork lasted from April to July 2015. Results: The study revealed that nurses’ age ranged between 20 and 60 years, 77.0% having nursing diploma. 38% of the nurses had satisfactory knowledge about documentation. 18% of the nurses agreed upon the barriers hindering the quality of nursing documentation. Conclusion: the nurses in the study setting have inadequate knowledge about documentation, and minorities of them agree about the barriers hindering quality of documentation. Nurses’ audited practice is low. Recommendations: staff development activities are urgently recommended to improve nurses' knowledge and practice.

Highlights

The quality of nursing documentation enables transparent and consistent approaches to the planning and delivery of care; it is the cornerstone for professional practice (Leach, 2008)
Nursing documentation is based on the nursing process so the client's needs can be traced from assessment, through identification of the problem solving to the care plan, implementation and evaluation (Ladner and Delaune, 2011)
The nurse was considered to “agree” on barriers if the percent score was 60% or more and “disagree”

Summary

Introduction

The quality of nursing documentation enables transparent and consistent approaches to the planning and delivery of care; it is the cornerstone for professional practice (Leach, 2008). Nurses communicate to other healthcare professionals their observations, decisions, actions and outcomes of care. Aim of the study: The study was aimed at assessing nurses' knowledge and auditing their practices regarding nursing care documentation. Subjects: Consisted o f 100 staff nurses and 557 nursing care charts. 38% of the nurses had satisfactory knowledge about documentation. 18% of the nurses agreed upon the barriers hindering the quality of nursing documentation. Conclusion: the nurses in the study setting have inadequate knowledge about documentation, and minorities of them agree about the barriers hindering quality of documentation. Recommendations: staff development activities are urgently recommended to improve nurses' knowledge and practice

Objectives

Results

Discussion

Conclusion