A Survey-Based Approach to Streamlining Nursing Documentation Practices at Hospital Settings

Abstract

Introduction: The meticulous recording of patient inf ormation not only f acilitates communication among healthcare providers but also plays a crucial role in maintaining patient saf ety. The manual nature of charting poses a risk of errors and can be time-consuming f or nurses. Objective: The study aim to explore the perspective of nursing observational charts practice at Pahang’s government hospitals in 2023.Method: This is a cross-sectional survey conducted among nurses across various hospitals in 2-monthduration. Af terrandomisation, nurses meeting the inclusion and exclusion criteria were enrolled in the study. Descriptive and inf erential statistics were computed to analyse the data. Result: A total of 582 nurses responded, the study f ound on average, 8.1 ± 2.7 SD standard charts were required during admission, and 3.0 ± 1.9 SD additional charts may required to supplement the standard charts per patient.Discussion: The study revealed that the adoption of a combined chart was associated with a 2.2 times improvement in the ease of nursing documentation practices.Conclusion: Having all relevant inf ormation in one place could reduce the need f or nurses to navigate through multiple f orms.