A clinical audit report on quality of nursing documentation at Jigme dorji Wangchuck national referral Hospital, 2018

Abstract

Introduction: Whether it is a written documentation or an oral communication, the practice and delivery of healthcare is debated to be critically dependent on effective and efficient communication. Nursing documentation is one of the principal sources of information about patient care and an important tool for communication. This descriptive study assessed both quantitative completeness and quality of nursing documentation by major in-patient units of Jigme Dorji Wangchuck National Referral Hospital. Methods: This cross-sectional study used D-catch tool. Data of randomly selected 317 patient records from six major in-patient units were entered into EpiData file. Using STATA version IC/14, descriptive statistics and multi variable analysis were carried out. Results: Overall quantitative completeness (M-3.4, SD-.59) of the nursing documentation was higher compared to the quality of the documents maintained (M-2.8, SD-.79). The basic and less time-consuming information such as admission data and vital signs charting are documented better compared to the more time consuming and complex documentation such as nursing care process. Conclusion: Systems should not only be in place to enhance documentation quantitatively but also consider uplifting the quality of the documents maintained. Initiating centralized admission system in the hospital may reduce nurses’ burden of clerical documentation, which will allow them to focus on quality nursing documentation and overall nursing care of patients.