Nursing Documentation Study at Teaching Hospital in KSA

Abstract

Nursing documentation is a legal record and a communication for continuity of care. Nurses should understand the implications of incorrect documentation could lead to sentinel events. The study aimed to examine the current practice of nursing care documentation and develop project for improvement. The project conducted from January to March 2014. It was based on the fundamental concepts of assessment; planning; implementation and evaluation. A prospective cross sectional method used to evaluate nursing 'Focus Chart' documents. Two nurses' documentation per unit per day for two weeks was assessed and analyze from all units using the hospital's measurement tool. Findings showed that 980 nurses are providing direct patients care and performing documentation on patients chart. Fifty percent (n= 16) unit has started focus charting and ten units are utilizing narrative and six units using other methods in documentation respectively. Documentation improvement package developed and processes put in place to readdress the documentation concern. The nursing care plan, patient assessment and activity flow sheets were reviewed and recommendation made to nursing administration to use a multidisciplinary approach to develop policies and guidelines on nursing documentation. In addition to provide sustained continuing training opportunities for nurses on effectiveness of documentation.