Physicians and nurses documentation practice at the University of Gondar Teaching Hospital, Northwest Ethiopia

Abstract

Introduction: quality medical documentation helps to explain the services provided to a particular person and enhance the exchange of information between health care providers. The objective of this study was to assess the documentation practice of physicians and nurses in a teaching hospital, University of Gondar, Ethiopia. Methods: A descriptive cross-sectional study was carried out with a total of 284 respondents who were selected with a stratified simple random sampling from January 8 to January 23, 2020. Data were collected using self-administered questionnaire. Data were entered using epi info version 7 and analyzed using SPSS version 20. Descriptive statistics was performed and then presented using tables. Respondent characteristics were summarized using frequency and percentages. A Chi-square test was used to investigate associations between the independent and outcome variables. Result: Less than half of the respondents (46.8%, n = 133) had a good medical documentation practice. Chi-squared test of association revealed no significant association on documentation practice with gender (χ2 = 1.48, df = 2 and p = 0.477) and respondent's profession (χ2 = 3.50, df = 1 and p = 0.065). Attitude (χ2 = 6.12, df = 1 and p = 0.013) and knowledge (χ2 = 57.6, df = 1 and p = 0.000) had association with documentation practice. Conclusion: and recommendation: As a conclusion, documentation practice of the respondents was inadequate. The working setting, supervision and feedback, standardized documentation sheets, in-service training, educational status, attitude, and knowledge of respondents to medical documentation had an association. It is advisable to perform trainings regarding standardized documentation sheets to enhance better documentation practice by health professions.

Keywords

• Documentation
• Documentation Practice
• Nurses
• Physician
• Practice