Investigating Nursing Documentation Practices and Influencing Factors: A Cross-Sectional Study in Public Hospitals of Ashanti Akim South District, Ghana
Thomas A Asafo Adjei
Nursing and Midwifery Training College, Tepa, Ghana.
Joseph Owusu-Marfo
Department of Epidemiology, Biostatistics and Disease Control, School of Public Health University for Development Studies, Tamale, Ghana and Catholic University, Fiapra- Sunyani, Ghana.
Albert Opoku *
Nursing and Midwifery Training College, Tepa, Ghana and Trinity Hospital Pankrono, Kumasi, Ghana.
Samuel Adomah
University of Traditional Medicine, Armenia.
*Author to whom correspondence should be addressed.
Abstract
Introduction: Nursing documentation is the record of nursing care planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse.
Objectives: The purpose of the study was to explore nursing documentation practice and associated factors among public hospital nurses in the Asante Akim South District.
Methodology: A cross-sectional design was used for the study. The study used nurses from public hospitals in the Ashanti Akim South district in the Ashanti region. A simple random sampling technique was used to select 136 nurses for the study. Data was collected with a questionnaire. Data entry, cleaning and analysis were done with SPSS version 26. Descriptive statistics including frequencies and their percentages were done. The chi-square test of independence and logistic regression analysis was done to determine the associated factors (significance at α=0.05).
Results and Discussion: The majority of study respondents were females. On the extent of clinical documentation majority of respondents perform. Work experience from 6 to 10 years, ward of operation and level of education influenced the extent of clinical documentation. About 23.5% of the respondents adequately identified common errors in patient records. Possible common errors identified by nurses included non-authorization of documents, improper cancellation of records, incomplete patient name and time, absence of biodata on recorded shows and illegible handwriting. Work experience for 6 to 10 years and 11 to 15 years, ward of operation and level of education influenced the identification of common errors.
Conclusion; The main mode of documentation was the paper-based handwriting method among 94.1% of respondents. Although the extent of clinical documentation among the nurses was good, the level of identifying common errors in documentation was low among nurses. Also, the use of manual paper-based handwriting methods of documentation at the hospitals needs urgent attention and possible review of the electronic medical records system.
Keywords: Nursing documentation, healthcare practitioners, medical records, nursing leadership