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.
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