Abstract:
Introduction: Documentation in nursing profession is a key factor in nurses‟ role and tasks as
patient care advocates. It is important for making sure if the quality of care was rendered to a
patient to defend prior nursing actions. Default to document, omissions, and poor communication
is not easy to defend.
Background: Since the time of Florence Nightingale, nursing documentation was viewed as
important and now it is still crucial in nursing by ameliorating patient care .The nursing
profession includes the law when it comes to caring for patients in all groups. The legal issues
can only be solved when there is accurate documentation.
Many nurses do not document and the omissions have been discovered in patient files in lowincome
countries.
Methodology: A quantitative cross sectional study was conducted. A number of 130 files of
hospitalized patient within 24hours in five wards (Emergency Department, Pediatric ward,
Internal medicine, surgical ward and Maternity) were audited. Microsoft excels and SPSS
versions 20 were used to analyze data and the patient‟s files were coded to ensure confidentiality.
Findings: Among audited files, temperature was recorded four times on 8 files (6.8%) as
recommended for the first 24 hours, pulse rate was recorded only on 14 files (11.8%), respiration
rate was recorded only on 3 files (2. 5%), blood pressure was recorded only on 11 files ( 9.2% ),
Oxygen saturation was recorded only on 12 files (10.1%). Fluid balance was not recorded on any
files 130 (0%). The nursing process was recorded only in 7% of audited files and in 93%, the
nursing process was never documented.
Conclusion: This study revealed that that the nursing documentations were not carried out as per
the recommendations and it needs to be improved at Gahini district hospital.
