Inter-Relationships of the Components of Documentation in Nursing Practice

Abstract

Although health care organizations use different systems and forms for documentation, all client records have similar information. This study explored the inter-relationships of the components of documentation in Nursing Practice. Documented nursing actions for 264 clients were obtained from six health care facilities (primary, secondary and tertiary levels) in Anambra State of Nigeria using multistage sampling technique. One research question and three null hypotheses guided the study. Checklist on nursing documentation in the clinical setting was used for data collection. Descriptive statistics on frequency distribution, means and Standard Deviation (SD) were used to summarize the variables. Pearson Product moment correlation was used to answer the research question and in testing the null hypotheses at 0.01 level of significance. The result showed that nursing action documentation had significant impact on Quality assurance r = 0.495, p-value = 0.000; core principles of nursing documentation was significantly related to timeliness of documentation (r = 0.650, p-value = 0.000) and promotion of inter-disciplinary communication (r = 0.736, p-value = 0.000), and that preciseness of nursing documentation had significant impact on quality assurance r = 0.590, p-value = 0.000. Clear, accurate and accessible documentation is an essential element of safe, quality, evidencebased nursing practice; and should always be ensured by nurses in all settings of practice.