Investigating Nursing Documentation Practices and Influencing Factors: A Cross-Sectional Study in Public Hospitals of Ashanti Akim South District, Ghana

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.