Knowledge and Practice of Tabriz Teaching Hospitals’ Nurses Regarding Nursing Documentation

Background: Nursing documents are vital for delivery of good and safe healthcare. Previous studies in Iran have shown that nursing documentation were inappropriate for evaluating patients' care but unfortunately not too many studies has examined the cause for this deficiency.

Objectives: To explore adequacy of nursing documentation and nurses' knowledge about the process.

Materials and Methods: The study was a cross-sectional study. The data were collected from 170 nurses who selected to participate in the study with census sampling method from 32 Medical–Surgical units at four university hospitals in Tabriz. For assessing the quality of nurses' documents, 2040 documents that were selected with simple random sampling were reviewed for content based on nursing process, legal accuracy, chronology and common items in flow sheets. Checklists were provided covering four areas: nursing records, drug interventions, vital sign and I&O of fluids. Nurses' knowledge were evaluated by prepared questionnaires. The instruments were evaluated for content validity. Estimation of inter- rater reliability was calculated for checklists and Kuder Richardson 21 was used for checking the reliability of nurses' knowledge questionnaire. Data was analyzed by SPSS software using One-way ANOVA and independent t test.

Results: The results showed that all of nursing records and vital sign flow sheets had average quality and insufficient information in legal accuracy, nursing care processes, and common items’ sections in vital sign flow sheets but most of fluids I & O flow sheets (81.4%) and drug interventions (85.9%) had good quality; however some degree of deficiency was present in these two sections, too. Most participants (85.9%) had limited knowledge regarding nursing documentation process.

Conclusions: Considering deficiencies in various parts of nursing documents such as nursing care processes, legal accuracy and some common items in vital sign and I & O fluid flow sheets and considering the nurses' insufficient knowledge towards nursing documentation, further coaching of nurses and encouraging them to work towards better documentation is needed for resolving nursing documentation insufficiencies.