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Nursing Documentation in Selected Hospitals in Khartoum State-Sudan

Year 2020, Volume: 6 Issue: 10, 108 - 120, 24.04.2020

Abstract

Nurses as a front line of patient care are accountable for maintaining accurate records. In Sudan, the tendency for documentation errors which accompanied by persistent shortage of nursing staff, lack of training and resources necessitate an evaluation of the quality of nursing documentation. To evaluate the quality of nursing documentation at selected hospitals in Khartoum, Sudan. Across sectional descriptive hospital-based study done during January to February 2019 in selected hospitals in Khartoum, Sudan; 237 nurses were interviewed using a structured questionnaire to assess their level of knowledge, training, and availability of documentation format; moreover, quality of nurses records assessed using checklists, data analyzed using SPSS. This study revealed that most of the nurses had good knowledge, did not train in documentation and agree with the availability of documentation format in their hospital with percent (69.00%), (74.7%) and (68.8%) respectively; besides, the quality of their documentation is poor due to limited use of nursing records and lack of training, policy-standers- procedures-guidelines. Their documents found rudimentary, and bad handwriting. Despite nurses’ documentation knowledge is good; due to lack of training, policy- guidelines, limited documentation, rudimentary and poor compared to that of developing countries.

References

  • 1. Alkouri, O. A., AlKhatib, A. J., Kawafhah, M. (2016). Importance And Implementation Of Nursing Documentation: Review Study. European Scientific Journal. 12, (3), 101-106. 2. Amesa, A. and Amugutsi, I. (2017). Nursing Documentation: A survey of Hemodialysis Documentation Status at Kenyatta NationalHospital’s Renal Unit. 1, American Research Journal of Nursing, 3,1- 9. 3. Andrews, A. and St Aubyn, B. (2015). If it’s not written down; it didn’t happen. Journal of Clinical Nurse , 29. 5,. 4. Andualem, A., Asmamaw, T., Sintayehu, M., Liknaw, T., Edmealem, A. (2019). Knowledge, attitude, practice and associated factors towards nursing care documentation among nurses in West Gojjam Zone public hospitals, Amhara Ethiopia. Clinical Journal of Nursing Care and Practice, 3,1-13. 5. Björvell, C., Wredling, R., Thorell‐Ekstrand, 1. (2003). Improving documentation using modle. Journal of advanced Nursing, 43. 4, 402-410, 6. Blair, W. and Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 412, (6), 160-168. 7. Chevakasemsook, A., Chapman, Y., Francis, K., Davies, C. (2006). The study of nursing documentation complexities. International Journal of Nursing Practice, 12, 366–74. 8. Grespan, V. and D'Innocenzo, M. (2009). Evaluation of the quality of nursing documentation though the review of patient medical records , Acta Paul. Enferm, 22. 3, . 9. Gugerty, B., Maranda, M.J., Beachley, M., Navarro, V.B., Newbold, S., Hawk, W., Karp, J., Koszalka, M., Morrison, S., Poe, S.S. and Wilhelm, D. (2007). Documentation Work Group. s.l. : Nursing Workforce Commission , A Report of the Maryland. USA. 10. Gunningberg, L., and Ehrenberg, A. (2004). Accuracy and quality in the nursing documentation of pressure ulcer : acomparison of record content and patient examination. J Wound Ostomy continence Nurs, 31, (6), 328-35. 11. https://www.srna.org. Retrived 15.09.2019 12. Idval, E. and Ehrenberg, A. (2002). Nursing documentation of postoperative pain management. Journal for clinical Nursing, 11(6):734-42. 13. Jasemi, M., Zamanzadeh, V., Rahmani, A., Mohajjel, A., Alsadathoseini, F. (2013). Nurses’ Knowledge and Practice Regarding Nursing Documentation at Tabriz Teaching Hospitals. Thrita Journal of Medical Sciences, 1, (4),133-138. 14. Jefferies, D., Johnson, M., Griffiths, R. (2010). Ameta-study of the essentials of quality nursing documentation. Int J Nurs Practice, 162, 112-24. 15. Johnson, M., Jefferies, D., Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. Journal of Nursing Management, 18, (7), 832-845. 16. Kalengo A. (2011). Knowledge, attitude and practice among nurses towards documentation of fluid balancechart at UTH Lusaka. Ref.: https://goo.gl/G92VbE. 17. Kamil, H., Rachmah, R., Elly W. (2018). What is the problem with nursing documentation? Perspective of Indonesian Nurses. International Journal of Africa Nursing Sciences, 9, 111–114. 18. Karkkaninen, O., and Eriksson, K. (2003). Evaluation of nursing records as apart of developing a nursing care classification. Journal of clinical Nursing, 12, (2),198-205. 19. Kizza, I. (2012). Nurses’ Knowledge and Practices Related to Pain Assessment in Critically ill Patients at Mulago Hospital, Uganda. MSc, Thesis, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. 20. Laudermilch et al: Laudermilch D, Meliss S, Nathens A, Rosengart M. Lack of emergency medical service docmentation is associated with poor patient outcomes: Avaldation of Audeit Filters for perhospital trauma care. Journal of American Colleg of Surgeons, Vol. 210.2, pp. 220-7. 21. Lee, T. (2005). Nursing diagnoses: factors affecting their use in charting standardized care plans. Journal of Clinical Nurse, 14.5, 640-7. 22. Machudo, S. and Mohidin, S. (2015). Nursing Documentation Project at Teaching Hospital in KSA. International Journal of Research in Science, 11, 4-7 . 23. Mohajjel, A., Lak, D., Rahmani, A., Hassankhani, H., Ahmadizadeh, A. (2012). Survey of Knowledge, Attitude and Performance of Nursing Students towards Nursing Documentation. European Journal of Scientific Research, 80, 191-198. 24. Mulugeta, E. (2015). Assessment Of Adult Postoperative Pain Management Practice Among Nurses Working In Addis Ababa Public Hospitals. http://localhost:80/xmlui/handle/123456789/8796 25. Mutshatshi, T., E., Mothiba, T. M., Mamogobo, P. M., . Mbombi, M. O. (2018). Record-keeping: Challenges experienced by nurses in selected public hospitals, Curationis, 41(1), 1-6. 26. Ofi, B., and Sowunmi, O. (2012). Nursing Documentation:Experience of the use of the Nursing Process Modle in Selected Hospitals in Ibadan Oyo State. Nigeria International Journal of Nursing Practice, 18, 354-362. 27. Okaisu, E., Kalikwani, F., Wanyana, G., Goetzee, M. (2014). Improving the quality of nursing documentation: An action research projrct. Curationis, 37, (2), 1-11. 28. Paans, W., Sermeus, W., Nieweg, R., Schans, C. (2010). Prevelance of accureat nursing documentation in patient records. Journal of Advanced Nursing, 66, (11), 2481. 29. Potter, P., Peree, A., Stokert, P., Haal, A. (2012). Fundamentals of Nursing. 8th edn . Publisher Mosby, pp. 324-363. 30. Urquhart, C., Urrell, R., Grant, M., Hrdiker, N. (2009). Nursing record systems: effect on nursing practice and health care outcomes. Cochrane Database of Systemic Review. 21, (1), CD002099. doi: 10.1002/14651858.CD002099.pub2.. 31. Vafaei, S., M., Manzari, Z., S., Heydari, A., Froutan, R., Farahani, L., M. (2018). Nurses’ perception of nursing services documentation barriers: a qualitative approach. Electron J Gen Med. 15, (3),1-8. 32. Wang, N., Hailey, D., Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: a mixed-method systemic review. Journal of Advanced Nursing, 67, (9),1858-75. 33. WHO (2014). World Health Organizations. Global Health Workforce Statistics, OECD, supplemented by country data, index mundi. Retrieved 10/ 2/ 2019, from index mundi: 2014, available in www.indexmundi.com. 34. Zegers, M. (2011). Quality of patient record keeping: an indicator of the quality of care. BJM quality and safety, 20 (4), 314.
Year 2020, Volume: 6 Issue: 10, 108 - 120, 24.04.2020

Abstract

References

  • 1. Alkouri, O. A., AlKhatib, A. J., Kawafhah, M. (2016). Importance And Implementation Of Nursing Documentation: Review Study. European Scientific Journal. 12, (3), 101-106. 2. Amesa, A. and Amugutsi, I. (2017). Nursing Documentation: A survey of Hemodialysis Documentation Status at Kenyatta NationalHospital’s Renal Unit. 1, American Research Journal of Nursing, 3,1- 9. 3. Andrews, A. and St Aubyn, B. (2015). If it’s not written down; it didn’t happen. Journal of Clinical Nurse , 29. 5,. 4. Andualem, A., Asmamaw, T., Sintayehu, M., Liknaw, T., Edmealem, A. (2019). Knowledge, attitude, practice and associated factors towards nursing care documentation among nurses in West Gojjam Zone public hospitals, Amhara Ethiopia. Clinical Journal of Nursing Care and Practice, 3,1-13. 5. Björvell, C., Wredling, R., Thorell‐Ekstrand, 1. (2003). Improving documentation using modle. Journal of advanced Nursing, 43. 4, 402-410, 6. Blair, W. and Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse, 412, (6), 160-168. 7. Chevakasemsook, A., Chapman, Y., Francis, K., Davies, C. (2006). The study of nursing documentation complexities. International Journal of Nursing Practice, 12, 366–74. 8. Grespan, V. and D'Innocenzo, M. (2009). Evaluation of the quality of nursing documentation though the review of patient medical records , Acta Paul. Enferm, 22. 3, . 9. Gugerty, B., Maranda, M.J., Beachley, M., Navarro, V.B., Newbold, S., Hawk, W., Karp, J., Koszalka, M., Morrison, S., Poe, S.S. and Wilhelm, D. (2007). Documentation Work Group. s.l. : Nursing Workforce Commission , A Report of the Maryland. USA. 10. Gunningberg, L., and Ehrenberg, A. (2004). Accuracy and quality in the nursing documentation of pressure ulcer : acomparison of record content and patient examination. J Wound Ostomy continence Nurs, 31, (6), 328-35. 11. https://www.srna.org. Retrived 15.09.2019 12. Idval, E. and Ehrenberg, A. (2002). Nursing documentation of postoperative pain management. Journal for clinical Nursing, 11(6):734-42. 13. Jasemi, M., Zamanzadeh, V., Rahmani, A., Mohajjel, A., Alsadathoseini, F. (2013). Nurses’ Knowledge and Practice Regarding Nursing Documentation at Tabriz Teaching Hospitals. Thrita Journal of Medical Sciences, 1, (4),133-138. 14. Jefferies, D., Johnson, M., Griffiths, R. (2010). Ameta-study of the essentials of quality nursing documentation. Int J Nurs Practice, 162, 112-24. 15. Johnson, M., Jefferies, D., Langdon, R. (2010). The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. Journal of Nursing Management, 18, (7), 832-845. 16. Kalengo A. (2011). Knowledge, attitude and practice among nurses towards documentation of fluid balancechart at UTH Lusaka. Ref.: https://goo.gl/G92VbE. 17. Kamil, H., Rachmah, R., Elly W. (2018). What is the problem with nursing documentation? Perspective of Indonesian Nurses. International Journal of Africa Nursing Sciences, 9, 111–114. 18. Karkkaninen, O., and Eriksson, K. (2003). Evaluation of nursing records as apart of developing a nursing care classification. Journal of clinical Nursing, 12, (2),198-205. 19. Kizza, I. (2012). Nurses’ Knowledge and Practices Related to Pain Assessment in Critically ill Patients at Mulago Hospital, Uganda. MSc, Thesis, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania. 20. Laudermilch et al: Laudermilch D, Meliss S, Nathens A, Rosengart M. Lack of emergency medical service docmentation is associated with poor patient outcomes: Avaldation of Audeit Filters for perhospital trauma care. Journal of American Colleg of Surgeons, Vol. 210.2, pp. 220-7. 21. Lee, T. (2005). Nursing diagnoses: factors affecting their use in charting standardized care plans. Journal of Clinical Nurse, 14.5, 640-7. 22. Machudo, S. and Mohidin, S. (2015). Nursing Documentation Project at Teaching Hospital in KSA. International Journal of Research in Science, 11, 4-7 . 23. Mohajjel, A., Lak, D., Rahmani, A., Hassankhani, H., Ahmadizadeh, A. (2012). Survey of Knowledge, Attitude and Performance of Nursing Students towards Nursing Documentation. European Journal of Scientific Research, 80, 191-198. 24. Mulugeta, E. (2015). Assessment Of Adult Postoperative Pain Management Practice Among Nurses Working In Addis Ababa Public Hospitals. http://localhost:80/xmlui/handle/123456789/8796 25. Mutshatshi, T., E., Mothiba, T. M., Mamogobo, P. M., . Mbombi, M. O. (2018). Record-keeping: Challenges experienced by nurses in selected public hospitals, Curationis, 41(1), 1-6. 26. Ofi, B., and Sowunmi, O. (2012). Nursing Documentation:Experience of the use of the Nursing Process Modle in Selected Hospitals in Ibadan Oyo State. Nigeria International Journal of Nursing Practice, 18, 354-362. 27. Okaisu, E., Kalikwani, F., Wanyana, G., Goetzee, M. (2014). Improving the quality of nursing documentation: An action research projrct. Curationis, 37, (2), 1-11. 28. Paans, W., Sermeus, W., Nieweg, R., Schans, C. (2010). Prevelance of accureat nursing documentation in patient records. Journal of Advanced Nursing, 66, (11), 2481. 29. Potter, P., Peree, A., Stokert, P., Haal, A. (2012). Fundamentals of Nursing. 8th edn . Publisher Mosby, pp. 324-363. 30. Urquhart, C., Urrell, R., Grant, M., Hrdiker, N. (2009). Nursing record systems: effect on nursing practice and health care outcomes. Cochrane Database of Systemic Review. 21, (1), CD002099. doi: 10.1002/14651858.CD002099.pub2.. 31. Vafaei, S., M., Manzari, Z., S., Heydari, A., Froutan, R., Farahani, L., M. (2018). Nurses’ perception of nursing services documentation barriers: a qualitative approach. Electron J Gen Med. 15, (3),1-8. 32. Wang, N., Hailey, D., Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: a mixed-method systemic review. Journal of Advanced Nursing, 67, (9),1858-75. 33. WHO (2014). World Health Organizations. Global Health Workforce Statistics, OECD, supplemented by country data, index mundi. Retrieved 10/ 2/ 2019, from index mundi: 2014, available in www.indexmundi.com. 34. Zegers, M. (2011). Quality of patient record keeping: an indicator of the quality of care. BJM quality and safety, 20 (4), 314.
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Details

Primary Language English
Subjects Health Care Administration
Journal Section Orginal Research
Authors

Aisha Mohammed Adam Ali This is me

Wala Ali Mustafa Albashir This is me

Abdalbasit Marıod 0000-0003-3237-7948

Publication Date April 24, 2020
Published in Issue Year 2020 Volume: 6 Issue: 10

Cite

APA Ali, A. M. A., Albashir, W. A. M., & Marıod, A. (2020). Nursing Documentation in Selected Hospitals in Khartoum State-Sudan. Journal of International Health Sciences and Management, 6(10), 108-120.
AMA Ali AMA, Albashir WAM, Marıod A. Nursing Documentation in Selected Hospitals in Khartoum State-Sudan. Journal of International Health Sciences and Management. April 2020;6(10):108-120.
Chicago Ali, Aisha Mohammed Adam, Wala Ali Mustafa Albashir, and Abdalbasit Marıod. “Nursing Documentation in Selected Hospitals in Khartoum State-Sudan”. Journal of International Health Sciences and Management 6, no. 10 (April 2020): 108-20.
EndNote Ali AMA, Albashir WAM, Marıod A (April 1, 2020) Nursing Documentation in Selected Hospitals in Khartoum State-Sudan. Journal of International Health Sciences and Management 6 10 108–120.
IEEE A. M. A. Ali, W. A. M. Albashir, and A. Marıod, “Nursing Documentation in Selected Hospitals in Khartoum State-Sudan”, Journal of International Health Sciences and Management, vol. 6, no. 10, pp. 108–120, 2020.
ISNAD Ali, Aisha Mohammed Adam et al. “Nursing Documentation in Selected Hospitals in Khartoum State-Sudan”. Journal of International Health Sciences and Management 6/10 (April 2020), 108-120.
JAMA Ali AMA, Albashir WAM, Marıod A. Nursing Documentation in Selected Hospitals in Khartoum State-Sudan. Journal of International Health Sciences and Management. 2020;6:108–120.
MLA Ali, Aisha Mohammed Adam et al. “Nursing Documentation in Selected Hospitals in Khartoum State-Sudan”. Journal of International Health Sciences and Management, vol. 6, no. 10, 2020, pp. 108-20.
Vancouver Ali AMA, Albashir WAM, Marıod A. Nursing Documentation in Selected Hospitals in Khartoum State-Sudan. Journal of International Health Sciences and Management. 2020;6(10):108-20.