Documentation is central to the management of patients in hospitals. Nurses are trained to follow the Ministry of Health Jamaica's policy on documentation, which is available in all public hospitals.Aim
Audit of documentation practices by registered nurses at a referral hospital.Methods
Ninety patient records from three medical wards were audited for documentation practices using an approved Jamaican Ministry of Health tool. Qualitative data regarding the nurses' experience with documentation were gathered from a focus group discussion of 12 nurses assigned to the audited wards.Findings
Most nurses (98%) followed documentation guidelines for admission by recording patients' past complaints, medical history and assessment data; used authorized abbreviations only (97%); documented nursing actions taken after identification of a problem and a provided a summary of the patients' condition at the end of the shift (98%). However, only 26% of the records had nursing diagnosis, which corresponded to the current medical diagnosis and 48% had documented evidence of discharge planning. Eighty-seven per cent had no evidence of patient teaching. The main reported factors affecting documentation practices were workload and staff/patient ratios. Participants believed that nursing documentation could be improved with better staffing, improved peer guidance and continuing education.Conclusions
The study showed high levels of accurate documentation by nurses at a referral hospital in Western Jamaica and the nurses appeared to be familiar with the required documentation guidelines with policy manuals available on each ward. Weaknesses in discharged planning and patient teaching were identified, which should be addressed by targeted continuing nursing.