Nursing documentation of inpatient care in eastern Ghana

Abstract

BACKGROUND: Despite the usefulness of a well-documented nursing care record, documentation still has its setbacks and receives varying levels of priority among nurses and other health professionals. However, since the quality and standard of patient care is often measured from retrospective records, it is imperative to examine the practice of nursing care documentation. AIM: The study described in this article examined current practices of nursing care documentation in Ghana. METHOD: By means of multiple sampling strategies, a retrospective approach was used to evaluate 100 patient care records in two hospitals between 1 November and 31 December 2012. FINDINGS: Major findings are that 46% of care given to patients was not recorded in the nursing care records; that nurses' progress notes were not written for 63% of patients after the first day of admission; and that 57% of documentation was not signed by nurses. CONCLUSION AND RECOMMENDATION: The standard of nursing care documentation is not on a par with that in developed countries, partly owing to a lack of guidelines, as well as a persistent shortage of nurses and the limited use of nursing care records. It is recommended that nursing stakeholders use a multidisciplinary approach to develop policies/guidelines on nursing care documentation and provide training opportunities for nurses on effective documentation.

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