The Accuracy of Documented Nursing Care Plan among Registered Nurses

Abstract

Background: Nursing documentation is a record of care planned and provided by qualified nurses under the guidance of a competent nurse for each patient as well as the clients. Objective: to provide published studies about accuracy of nursing documentation. Methods: Searches were conducted using the following electronic databases: PUBMED, MEDLIN, CINAHAL, SAUDI DIGETAL LIBRALY and GOOGLE SCOLAR as gray data base. Search was limited to English-Language publication. And include study over 10year period. Result: nursing documentations is inaccurate, lacking precision, and low in quality.  Factors that influence nursing documentation differ but are also interrelated with each other. Shortage of employees, insufficient knowledge about the significance of documentation, patient load, lack of hospital education, and lack of support from nurse leaders are the reported challenges to documentation. Conclusion: Most of the lecture revel the necessary need of nursing documentation practice. Affected factor and with several recommendations for improvement noted. Keywords:  ''nursing care plan," "nursing documentation,'' "accuracy of documentation" and ''nursing report.''