An Audit of Nurses’ Clinical Documentation Practices; the Case of Baptist Medical Centre, Nalerigu

Abstract

Nursing documentation is an important routine in the practice setting with nurses required to record each and every care activity appropriately and adequately. It is worth mentioning, the coordination and continuity of patient care largely depend on communication between nurses, other members of the healthcare team of which nursing documentation play a key role. Notwithstanding the Ghanaian practice experience, the status of nurses’ documentation has not been adequately examined. This study sought to assess the nurse’s clinical documentation practices at the Baptist Medical Centre. A cross-sectional retrospective study was conducted using systematic random sampling method, 240 patient folders were selected from the Medical, Surgical and Paediatric wards. Data analysis was conducted using International Business Machines Corporation- Statistical Package for the Social Sciences (IBM-SPSS) version 21. Mean, Standard Deviation, Frequencies, Multiply logistic regression and One Sample t test were used to analyse the data. The study showed general percentage score of documentation at (n=145, 60.5%) which was at low level when compared with the standard practice as established. Major routines documentation reviewed revealed incidences of incomplete, illegible and not concise entries, (n=60, 25%) entries had date and time of nursing care activities documented (n=94, 39.2%). The results further shows that nurses documentation practices were above average compared to the standard for legal accuracy (M = 10.25, SD = 1.074). The use of the nursing process was (n=109, 45.4%) at alarming low level for care in the documentation. Nursing assessment documentation was below the acceptable standard (n=5, 2.1%), as with nursing diagnosis (n=208, 86.7%) and (n=154, 64.6%) been absent of entries for intervention documentation. Patient progress report was not documented for (n=134, 55.8%), education and discharge teaching were not documented at an alarming rate (n=234, 97.5%) and (n=237, 98.8%) of the folders reviewed. The study recommends for regular in-service training for the nurses to refresh their records keeping skills as well as the periodic monitoring and evaluation of the practices for improvement.