essay on nursing documentation

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• Published: 28 January 2022

Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses

• Kim De Groot 1 , 2 ,
• Anke J. E. De Veer 1 ,
• Anne M. Munster 3 ,
• Anneke L. Francke 1 , 4 &
• Wolter Paans 5 , 6  

BMC Nursing volume  21 , Article number:  34 ( 2022 ) Cite this article

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The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses’ views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload.

A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman’s rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed.

The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses’ perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records.

Conclusions

Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.

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Clinical nursing documentation is essential in letting nurses continuously reflect on their choice of interventions for patients and the effects of their interventions. Therefore, it is vital to the quality and continuity of nursing care [ 1 , 2 ]. Nursing documentation can be described as a reflection of the entire process of providing direct nursing care to patients [ 3 , 4 , 5 ]. Consequently, there is international consensus that clinical nursing documentation has to reflect the phases of the nursing process, namely assessment, diagnosis, care planning, implementation of interventions and evaluation of care or – if relevant – handover of care [ 2 , 3 , 6 , 7 , 8 ].

Despite the evident importance of nursing documentation, time spent on documentation can be substantial and therefore it can be experienced as onerous for nurses. Research indicates documentation time has reached an extreme form [ 9 , 10 , 11 ]. Even though the actual time spent by nurses on documentation varies internationally, it is a substantial part of the work of nurses [ 12 , 13 ]. For example, in Canada nurses spend about 26% of their time on documentation [ 14 ], in Great Britain 17% [ 15 ] and in the USA percentages vary from 25% to as much as 41% [ 16 , 17 ]. In the Netherlands, nursing staff reported spending an average of 10.5 hours a week on documentation [ 18 ], which means they spend about 40% of their time on documentation.

The variation between countries in nurses’ time spent on documentation may be related to differences in electronic health records and the way in which handovers are organized. However, the variation may also be the result of a lack of clarity about what qualifies as documentation [ 19 , 20 ]. Some studies used the term ‘documentation’ for activities that were directly related to individual patient care, e.g. drawing up a care plan or writing progress reports [ 16 , 17 ]. Other studies used ‘documentation’ as an umbrella term that included ‘non-patient-care-related’ documentation as well, such as recording hours worked or recording data for the planning of personnel [ 18 , 20 ].

A conceptual overview from the Organisation for Economic Cooperation and Development (OECD) provides more conceptual clarity in the various types of documentation [ 12 ]. The OECD states that documentation generally can be divided into clinical documentation and documentation regarding organizational and financial issues. Clinical documentation refers to documentation in the electronic health records of individual patients, e.g. about the patient’s medical condition and about the care provided by healthcare professionals. The OECD uses the term ‘organizational documentation’ to refer to the documentation of issues regarding personnel planning and coordinating different shifts, for instance. Documentation such as recording hours worked for the purpose of billing and insurance are categorized by the OECD as financial documentation [ 12 ].

There are indications that organizational and financial documentation in particular has increased in the last decade, which might be explained by the rising demand for accountability and efficiency of care [ 21 ]. Since documenting organizational and financial issues is not directly related to patient care, these aspects of documentation might be perceived negatively by nurses [ 22 ]. In contrast, nurses might be more open to clinical documentation since this documentation is essential to high-quality nursing care [ 1 , 2 , 23 ]. Moreover, according to professional standards and guidelines, clinical documentation should be considered as an integral part of providing nursing care [ 24 , 25 , 26 ].

Still, lengthy clinical documentation might be challenging for nurses as well. According to Baumann, Baker [ 27 ], Moore, Tolley [ 28 ] the implementation of electronic health records for individual patients appeared to increase the observed time that nurses spend on clinical documentation. Yet their findings were inconclusive, since long-term follow-up studies indicated decreasing documentation time once nurses became familiar with the electronic health records [ 27 ]. However, other studies indicated that the setup for the electronic health records does not always match nurses’ routines and can therefore be a potential source of perceived time pressure among nurses [ 29 , 30 ]. Yet when the electronic health records follow the phases of the nursing process, this might be supportive for nurses’ clinical documentation [ 31 ].

Nurses’ time pressure and nursing workload have received significant interest, in part because nursing shortages are a problem internationally [ 32 ]. Research often focusses only on the objective nursing workload, measured and expressed in actual time spent caring for a patient and/or staffing ratios [ 33 ]. However, nurses’ emotional or perceived workload might not always correspond to their objective workload [ 34 ]. But the perceived workload of nurses and the related factors is a rather unexplored area. For instance, it was unknown to date if perceived workload is associated with specific types of documentation activities and the actual time spent on these activities.

In line with the above-mentioned conceptual overview from the OECD [ 12 ] and from a nursing perspective, it seems relevant to make a distinction between different types of documentation activities. On the one hand, there is clinical documentation, which directly concerns the nursing care for individual patients. On the other hand, there is organizational and financial documentation; this is documentation that is mainly relevant for care organizations, management, policymakers and/or health insurers. In the Dutch context, clinical documentation often includes care needs assessment information, a care plan structured according to the phases of the nursing process, daily evaluation reports concerning the care given, and the handover of care. Organizational and financial documentation often concerns records of hours worked, expense claims for medical aids, reports on incidents with patients and/or employees, internal audits, and measurements of employee satisfaction and/or patient satisfaction.

To date it was unclear whether specific types of documentation are associated with a high perceived nursing workload. Distinguishing between types of documentation may provide more insight into the possible relationship between documentation and perceived nursing workload.

Furthermore, we used a mixed-methods approach to gain a deeper understanding, with a quantitative survey followed by qualitative focus groups. The quantitative data provided a broad and representative picture of the possible presence of a relationship between perceived workload and documentation activities. However, the reasons why community nurses felt the specific documentation activities increased their workload became clearer from the qualitative data. Combining the findings from these two methods resulted in a credible and in-depth picture of the relationship between documentation activities and perceived nursing workload. This enabled specific recommendations to be made that can help reduce the workload of nurses.

Such insights are relevant in particular for the home-care setting, since a previous survey showed that community nurses reported spending even more time on documentation compared with nurses working in other settings [ 18 ]. In addition, most studies on the documentation burden focus solely on the hospital setting, e.g. the studies of Collins, Couture [ 35 ] and Wisner, Lyndon [ 30 ].

Therefore, the study presented here aimed to gain insight into community nurses’ views on a potential relationship between clinical and organizational documentation and the perceived nursing workload (in this study, ‘organizational documentation’ includes financial documentation). The research questions guiding the present study were:

(a) Do community nurses perceive a high workload due to clinical and/or organizational documentation? ( survey and focus groups ), (b) If so, is their perceived workload related to the time they spent on clinical and/or organizational documentation? ( survey ).

Is there a relationship between the extent to which community nurses perceive a high workload and (a) the user-friendliness of electronic health records ( survey and focus groups ), and (b) whether the nursing process is central in the electronic health records ( survey and focus groups )?

A convergent mixed-methods design was used, in which a quantitative survey with qualitative focus groups were combined to develop in-depth understanding of the relationship between documentation activities and perceived nursing workload [ 36 , 37 ]. This design has been proven to be particularly useful for achieving a deep understanding of relationships [ 36 , 38 ]. First, the quantitative survey was performed and findings from this quantitative component were subsequently enriched by the findings of the qualitative focus groups [ 37 , 38 ].

Participants

Survey participants.

The nurses who were sent the online survey were participants drawn from a Dutch nationwide research panel known as the Nursing Staff Panel ( https://www.nivel.nl/en/panel-verpleging-verzorging/nursing-staff-panel ). Members of the Nursing Staff Panel are primarily recruited through a random sample of the population of Dutch healthcare employees provided by two pension funds [ 4 ]. In addition, members are recruited through snowball sampling and open calls on social media. All members had given permission to be approached regularly to answer questions about their experiences in nursing practice. For this study, the survey was sent by email to all 508 community nurses who were members of the Nursing Staff Panel. Since this is a nationwide panel, respondents worked in a variety of organizations across the Netherlands. To increase the response rate, two electronic reminders were sent to nurses who had not yet responded.

This paper focusses on community nurses and electronic nursing documentation; therefore only respondent nurses who met the following criteria were included in the analysis: 1) being a registered nurse with a bachelor’s degree or a secondary vocational qualification in nursing; 2) working in home care; 3) using electronic health records. We excluded 24 respondents who did not meet these criteria.

Focus-groups participants

Focus-group participants were recruited through the professional network of two authors (KdG and AM), open calls on social media (LinkedIn and Facebook), and through snowball sampling. Nurses were eligible to participate in a focus group if they met the same inclusion criteria as used for the survey participants. Purposive sampling was applied to obtain variation among participants regarding the educational level, age and standardized terminology used in the electronic health records. None of the participants of the focus groups had also participated in the survey.

Since the focus groups were in addition to the survey, we expected a priori that four focus groups would be enough to reach data saturation. This expectation was met, as the last focus group produced no new insights that were relevant for answering the research questions.

Data collection

The survey data were collected from June to July 2019. We used an online survey questionnaire that mostly consisted of self-developed questions as, to our knowledge, no instrument was available that included questions on both clinical documentation and organizational documentation. The extent to which nurses perceived a high workload was measured using a five-point scale (1 = ‘never’ to 5 = ‘always’). We distinguished between a high workload due to clinical documentation and a high workload due to organizational documentation. We included financial documentation in our definition of organizational documentation. In the questionnaire we explained the content of the two types of documentation. Respondents were then asked to estimate the time they spent on the two types of documentation.

Next, two questions focussed specifically on clinical documentation, namely whether the electronic health record of individual patients was user-friendly and whether the nursing process was central in this record. These questions were derived from the ‘Nursing Process-Clinical Decision Support Systems Standard’, an internationally accepted and valid standard for guiding the further development of electronic health records [ 31 ].

The entire questionnaire was pre-tested for comprehensibility, clarity and content validity by nine nursing staff members. Based on their comments, the questionnaire was modified, and a final version produced. A translation of the part of the questionnaire with the 11 questions relevant for this paper can be found at: https://documenten.nivel.nl/translated_questionnaire.pdf .

Focus groups

After the survey, we conducted four qualitative focus groups from February to May 2020. Each group consisted of six or eight community nurses, with a total of 28 community nurses. These focus groups were performed in order to deepen and refine the insights gained from the survey data.

The focus groups were led by two authors (KdG and AM) and supported by an interview guide with open questions, see Table  1 . The questions were inspired by the results of the survey data, e.g. they addressed how community nurses perceived clinical and organizational documentation in relation to their workload, or how community nurses experienced the user-friendliness of electronic health records.

Initially, we aimed to conduct all the focus groups face-to-face at the care organizations’ offices. However, after one face-to-face focus group we had to switch to online focus groups due to the COVID-19 pandemic. Online focus groups in which participants post written responses in a secure online discussion site have been proven to be an appropriate alternative for face-to-face focus groups [ 39 , 40 , 41 ]. In fact, the online focus groups had several advantages, such as providing participants with the ability to access, read and respond to posts at a place and time most convenient to them [ 40 , 41 ]. This was particularly advantageous for nurses during the pandemic.

Each online focus group was conducted within a set period of 2 weeks. Two authors (KdG and AM) acted as moderators by regularly checking the responses and posting new questions every 2 days, except in the weekend. The analysis of the transcripts has shown that the findings from the online focus groups were comparable to those from the face-to-face focus group.

Data analysis

Analysis of the survey.

Descriptive statistics were used to describe the background characteristics of the respondents and to answer the first and second research questions. Wilcoxon signed-ranked tests were conducted to answer the first research question (1a), since the two variables measuring the perceived workload were ordinal and the two variables measuring the estimated time spent on documentation were not normally distributed. Next, the potential relationships between perceived workload and time spent on documentation (research question 1b) were examined using Spearman’s rank correlations. Wilcoxon rank-sum tests were conducted to examine associations between perceived workload and user-friendliness (research question 2a) and the nursing process (research question 2b). The level for determining statistical significance was 0.05. Analyses were conducted using STATA, version 16.1.

Analysis of the focus groups

The audio recording of the face-to-face focus group was transcribed verbatim. Transcripts from the online focus groups were taken directly from the discussion site.

The focus-group transcripts were analysed using an iterative process of data collection - data analysis - more data collection. Within this process, the six steps of thematic analysis were followed, namely becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting [ 42 ].

The transcripts of all the focus groups were analysed by two authors (KdG and AM). They refined their analyses in discussions together and with two other authors (AF and WP), which ultimate led to consensus about the main themes. This triangulation of researchers was used to increase the quality and trustworthiness of the analysis [ 43 ]. Moreover, ‘peer debriefing’ was applied with a group of peer researchers who were not involved in the study. In addition, confirmability of the findings was enhanced by including verbatim statements made by participants in the results section of this paper. Furthermore, the quality of the reporting was ensured by following the guidelines in ‘Good Reporting of A Mixed Methods Study’ [ 44 ].

Data integration

By integrating data from the quantitative and qualitative components, an in-depth and credible picture was obtained of the relationship between specific documentation activities and perceived nursing workload [ 36 , 37 ]. The data were integrated using two integration approaches. Firstly, we compared the data from the survey and focus groups in the analysis process, in discussions among the authors, and in the ‘ Discussion ’ section of this article. This is referred to as the ‘merging’ approach [ 37 ]. For instance, the survey result on how many nurses perceived a high workload from clinical documentation activities was compared to the focus groups results on nurses’ views as to why they did or did not perceive a high workload from these activities. Secondly, integration through narratives was performed when reporting the results. Hereby we used a ‘weaving’ approach in which we brought the findings from the quantitative survey and qualitative focus groups together on a thematic basis and arranged them according to the research questions [ 37 ].

Ethical considerations

The study was conducted in compliance with the principles of the General Data Protection Regulation, by strictly safeguarding the anonymity of the participants. Formal approval from an ethics committee was not required under the applicable Dutch legislation on medical scientific research as participants were not subjected to procedures and were not required to follow rules of behaviour (see https://english.ccmo.nl/investigators/legal-framework-for-medical-scientific-research/your-research-is-it-subject-to-the-wmo-or-not ).

Participants in the survey had all consented to being sent and completing surveys on a regular basis on topics directly related to their work when they signed up as members of the Nursing Staff Panel. Potential participants of the focus groups were informed about the study in an information letter. If desired, they could obtain additional verbal information. All participants signed an informed consent form before the focus groups started.

All methods were applied in accordance with relevant guidelines and regulations.

A total of 195 community nurses completed the questionnaire (response rate 38.4%). Since a substantial group did not respond, we conducted non-response analyses. We found no statistically significant differences between the respondents and non-respondents regarding gender, level of education and number of hours employed. We did however see a difference in age: the respondents were somewhat older (mean age 49.8 years) than the non-respondents (mean age 44.3 years). We reflect on the relatively high age of the survey respondents in ‘ Limitations and strengths ’ section.

A total of 28 community nurses participated in the four focus groups. The characteristics of the participants are presented in Tables  2 and 3 .

Perceived workload due to documentation and time spent documenting

More than half of the community nurses in the survey said that they perceived a high workload due to clinical and/or organizational documentation, see Table 4 . A majority (52.4%) said that they regularly to always experienced a high workload due to clinical documentation. Regarding organizational documentation, 58% of the nurses reported a high perceived workload. No statistically significant differences in perceived workload were found between the two types of documentation (Wilcoxon signed-ranked test: p  = 0.124). In other words, nurses were just as likely to experience a high workload due to clinical documentation as due to organizational documentation.

Community nurses in the survey estimated that they spent on average 8.0 (SD 6.0; median 6.0) hours a week on clinical documentation. They estimated that they spent significantly less time on organizational documentation, namely on average 3.6 (SD 4.0; median 2.0) hours a week (Wilcoxon signed-ranked test: p  < 0.000).

Looking at clinical documentation, no statistically significant correlation was found between nurses’ estimated time spent on this type of documentation and their perceived high workload (Spearman’s rank correlation 0.135; p  = 0.058). However, looking at organizational documentation, a statistically significant moderate correlation was found between time spent on documentation and perceived high workload (Spearman’s rank correlation 0.375; p  < 0.000). This showed that nurses who spent more time on organizational documentation were more likely to perceive a high workload.

In general, the community nurses participating in the qualitative focus groups experienced a high workload due to documentation as well. They described organizational documentation in particular as cumbersome, redundant and too repetitive in nature. Even though nurses believed that a high workload in general is common among community nurses, they did see documentation as one of the causes for their high workload.

“You are already busy sorting out all the shifts, all the patients who are starting and stopping home care etc. There’s already a high workload. And on top of all that, there are the documentation activities. In our organization, they also want everyone to do refresher courses to keep their registration as a nurse, so you need to register that too. That is another extra documentation burden, and that takes up extra time too.” (Focus group 1, face-to-face).

A general picture that emerged from the focus groups is that organizational documentation was a key reason for community nurses’ perceived workload, while this was less so for clinical documentation. Community nurses in the focus groups said that they often failed to see the added value of organizational documentation for their patients and themselves. Therefore they had a feeling of frustration with the organizational documentation, associated with a high perceived workload.

“I think the frustration comes much more from the organizational side. From powerlessness because of all the pointless things you don’t really have time for.” (Focus group 1, face-to-face).

Focus-group participants mentioned that various rules and regulations imposed by their employers and/or national organizations, such as health insurers, also affected the amount of organizational documentation. They perceived a high workload when they had to register information only for the sake of these rules and regulations.

“Whenever someone in the organization starts talking about reducing the documentation burden, my blood pressure starts to rise. Then I know for certain that it’ll come back in spades some other way: someone else’s documentation burden will be reduced, but not mine.” (Focus group 1, face-to-face).

Community nurses in the focus groups were more positive about their clinical documentation activities. They found clinical documentation necessary and useful for providing good nursing care. For them it was evident that this documentation was an important part of their work. Because they saw clinical documentation as directly connected to individual patient care, they were less negative about the time they had to spend on clinical documentation compared with organizational documentation. Some nurses did however mention that documenting the formal care needs assessment (which is a requirement for home care financed by health insurers in the Netherlands) consumed a lot of their time. Still, nurses did not find this kind of documentation burdensome due to the perceived relevance and usefulness of the documentation of the care needs assessment. This was also the case for clinical documentation relating to individual patient care in general.

“The documentation activities I carry out for my patients are appropriate for my job and the documentation is not an additional burden. On the contrary, that documentation helps me and my fellow nurses to give our patients good, appropriate care.” (Focus group 4, online).

Perceived workload and features of electronic health records

Elaborating further on clinical documentation specifically, we explored the perceived workload in relation to two features of the electronic health records, namely user-friendliness and whether the record matches with the nursing process.

User-friendliness of electronic health records in relation to workload

Most of the community nurses in the survey agreed that the electronic health records in which they documented information about the nursing care for individual patients were user-friendly (78.8%). A smaller group disagreed (17.6%) and a few did not know (3.6%). The survey participants who answered ‘don’t know’ were excluded from the analysis of the association between user-friendliness and the perceived workload. No statistically significant association was found between how often the nurses perceived a high workload and the user-friendliness of electronic health records (Wilcoxon rank-sum test: p  = 0.166), see Table  5 .

As for the user-friendliness of electronic health records the opinions and experiences of the community nurses in the qualitative focus groups were divided. While several community nurses were positive about the user-friendliness of the electronic health records, others were less positive. The latter group said that the limited user-friendliness was one reason why they spent so much time on documentation and experienced a high workload. Elaborating on the limited user-friendliness, nurses in the focus groups explained that some mandatory sections or headings in the electronic health records, e.g. about wound care, cost them too much time. They did not always see the added value of filling in those sections, making this a burdensome activity. Furthermore, nurses stated that the fact that they often had to switch between different sections of the electronic health record was time-consuming and burdensome for them as well.

“I also find it a pain that you need to search in different sections for a lot of things. The care plan describes that you have to perform wound care according to the wound policy, but the wound policy itself is under a different heading than the care plan. Then the reports about the wound are under the care plan again. And if the patient also needs help with ADL, you have to go back via the care plan again. It all costs extra time and you have to do a lot of clicking.” (Focus group 3, online).

Focus-group participants also addressed another issue regarding the limited user-friendliness of the electronic health records in relation to their workload. This is the large diversity in electronic systems used within and across care organizations and professionals. For instance, nurses said that they used different systems for documenting wound care and for documenting the medication check. Furthermore, other healthcare professionals, such as general practitioners or pharmacists, often use different electronic systems for their clinical documentation. Community nurses stated that these systems are often not linked to one another, resulting in duplicate documentation activities for nurses and increasing their workload.

“We have at least a dozen systems and only a few are linked to each other. [...] The systems for communicating with other disciplines and medication systems aren’t linked to one another. Despite the positive discussions, you’re still dependent on the preferences of the pharmacist or GP as to what systems are used. That can lead to you having three different medication systems in one team, for example.” (Focus group 4, online).

Nursing process in electronic health records in relation to workload

In the survey, the majority of community nurses agreed that the nursing process was central in their electronic health records (78.7%). Some nurses disagreed (17.2%) and a few did not know (4.2%). To examine a possible association with workload, survey participants who answered ‘don’t know’ were excluded from this analysis. No statistically significant association was found between a perceived high workload and whether the nursing process was central in the records (Wilcoxon rank-sum test: p  = 0.542), see Table  6 .

Like the survey respondents, virtually all community nurses in the focus groups were positive about how the nursing process was integrated in the electronic health records they worked with.

“I think we have a very nice system that functions well. [...] I also get sufficient support from this system in my task as a community nurse monitoring the nursing process.” (Focus group 4, online).

Hence, this feature of the electronic health records was not associated with the workload of the community nurses.

The present study revealed that the majority of community nurses participating in the survey and focus groups perceived documentation as a cause of their high workload. These findings are in line with previous research that indicated that documentation can be burdensome to nurses [ 9 , 10 ]. Although community nurses spent twice as much time on clinical documentation compared to organizational documentation, the survey showed that community nurses were just as likely to perceive a high workload due to clinical documentation as to organizational documentation. In the focus groups, nurses indicated that organizational documentation in particular was a cause of their high workload. They were more positive about clinical documentation since they experienced that as a meaningful and integral part of the care for individual patients. This view is in line with professional guidelines that describe clinical nursing documentation as an integral part of nursing care for individuals [ 24 , 25 , 26 ].

Nevertheless, the survey in particular showed that community nurses often did perceive a high workload due to clinical documentation as well. In the focus groups participants had more opportunity to reflect on and to discuss the value of clinical documentation versus organizational documentation, and this may have resulted in more positive views on clinical documentation.

Still, it is rather surprising that particularly in the survey clinical documentation was associated with a high workload by so many community nurses. Previous research by Fraczkowski, Matson [ 45 ];Michel, Waelli [ 20 ];Moy, Schwartz [ 46 ];Vishwanath, Singh [ 47 ];Wisner, Lyndon [ 30 ] indicated that electronic clinical documentation is associated with documentation burden by health care professionals. It seems important that all nurses are made aware that clinical nursing documentation is important for providing good patient care. This awareness might reduce nurses’ perceived workload associated with documentation activities. On top of that, further integrating clinical documentation in individual patient care and improvements in the electronic health records are needed [ 45 , 48 ].

For optimal integration of clinical documentation in patient care, it is important that the electronic health records reflect the phases of the nursing process [ 6 , 31 ]. However, our study showed no association between the extent of nurses’ perceived workload and whether the electronic health records was following the nursing process. A possible explanation is that most community nurses (78.7%) already found that the nursing process was central in their electronic health records.

A key recommendation for care organizations and software developers is to improve electronic health records in terms of their user-friendliness [ 4 , 31 ]. Other recent studies also linked the limited usability or user-friendliness of electronic health records to nurses’ perceived time pressure [ 29 , 49 ]. The community nurses participating in the focus groups also recommended improvements in the user-friendliness of electronic health records and stated that that would reduce their workload. Examples would be removing mandatory sections in electronic health records and working on better communication between systems within and across care organizations and healthcare professionals.

Furthermore, focus-group participants recommended linking the content of the different electronic systems for clinical and organizational documentation so that relevant information only has to be documented once. Other research also indicated that duplication in documentation is a problem for nurses and is accompanied with negative views on documentation [ 11 ]. Moreover, studies showed a poor match between different electronic health records both in the digital formats that are used and in the professional vocabulary and standard terminologies used [ 50 , 51 ]. Improvements in electronic health records, linkages between different electronic systems and more uniformity in language could facilitate information sharing with other healthcare professionals and interdisciplinary care [ 48 , 52 ].

Another finding in our study was that although clinical documentation was also associated with a high workload, time spent on organizational documentation was considered even more problematic. Unlike clinical documentation, organizational documentation was often seen as pointless. Spending a great deal of time on organizational documentation gave feelings of frustration and a high perceived workload. Our study did not differentiate between different kinds of organizational documentation in terms of the aims of the documentation, e.g. financial accountability for insurers, quality indicators for the Health Inspectorate, safety and quality management for the nurse’s own care organization, etcetera. The association between the specific aims of organizational documentation and nurses’ perceived workload could be a subject for future research. In addition, further research should focus on the integration of clinical documentation in patient care and the user-friendliness of electronic health records.

Limitations and strengths

A limitation of this mixed-methods study is that the survey participants and focus-group participants differed in age: the focus-group participants were on average younger than the survey participants. We looked at the survey data for a possible correlation between age and perceived workload but did not find statistically significant differences.

A second limitation is that we used a self-developed survey questionnaire. However, we based the questionnaire on relevant literature, including the ‘Nursing Process-Clinical Decision Support Systems Standard’ [ 12 , 31 ]. Furthermore, we tested the questionnaire in a pilot study for comprehensibility among nursing staff. Hence, we consider the questionnaire to be a comprehensive and content valid instrument to assess nurses’ experiences with documentation in relation to their perceived workload.

A strength of this study was the use of mixed-methods research, which provided a deeper understanding of community nurses’ documentation activities in relation with their perceived workload. The focus groups that were organized after the survey gave additional and more in-depth insights, particularly regarding nurses’ views on the two types of documentation and the user-friendliness of electronic health records.

The majority of community nurses regularly perceived a high workload due to documentation activities. Although nurses spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these types of documentation was comparable. The extent to which nurses perceived a high workload was related to time spent on organizational documentation in particular. Nurses believed spending substantial time on clinical documentation was worthwhile, while spending a great deal of time on organizational documentation led to frustration. Therefore, a reduction in the time needed specifically for organizational documentation is important.

Particularly in the focus groups, nurses highlighted the importance of user-friendly electronic health records in relation to perceived workload. Improving the user-friendliness of electronic health records, improving the intercommunicability of different electronic systems, and further integrating clinical documentation in individual patient care are also recommended as measures to reduce the workload that community nurses perceive from documentation activities.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Acknowledgements

We would like to thank the participants of the Dutch Nursing Staff Panel and all other community nurses who participated in this study. Furthermore, we thank Clare Wilkinson for the language editing.

The Dutch Nursing Staff Panel is financed by the Ministry of Health, Welfare and Sports. The funder had no role in conducting this research. No specific funding was received for the focus groups.

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KdG, AdV, AF and WP developed the study concept and design. KdG, AdV and AM carried out the data collection. All authors (KdG, AdV, AM, AF, WP) contributed to the analysis and interpretation of the data. All authors contributed to the drafting and revision of the article. All authors read and approved the final manuscript.

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De Groot, K., De Veer, A.J.E., Munster, A.M. et al. Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses. BMC Nurs 21 , 34 (2022). https://doi.org/10.1186/s12912-022-00811-7

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how to series    

How to undertake effective record-keeping and documentation, nicola brooks associate dean (academic), faculty of health and life sciences, de montfort university, leicester, england.

• To familiarise yourself with the importance of keeping clear and accurate patient records

• To understand the approach for writing clear records that are free of jargon and speculation

• To learn about patients’ rights in relation to accessing their medical records

Rationale and key points

Effective record-keeping and documentation is an essential element of all healthcare professionals’ roles, including nurses, and can support the provision of safe, high-quality patient care. This article explains the importance of record-keeping and documentation in nursing and healthcare, and outlines the principles for maintaining clear and accurate patient records.

• Nurses’ regulatory standards for practice emphasise the importance of maintaining clear and accurate patient records.

• Patient records provide evidence of the assessments and interventions that have been undertaken. They can facilitate continuity of care by enabling other healthcare professionals to clearly see patients’ current care plans and treatments.

• The policies and procedures for maintaining patient records can vary between healthcare organisations, so it is important for nurses to check these and practice in accordance with them.

Reflective activity

‘How to’ articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of:

• How this article might enhance your practice, in terms of effective record-keeping and documentation.

• How you can use the information in this article to educate nursing students and colleagues on the importance and principles of effective record-keeping and documentation.

Nursing Standard . doi: 10.7748/ns.2021.e11700

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@Nicola44828048

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None declared

Brooks N (2021) How to undertake effective record-keeping and documentation. Nursing Standard. doi: 10.7748/ns.2021.e11700

Disclaimer Please note that information provided by Nursing Standard is not sufficient to make the reader competent to perform the task. All clinical skills should be formally assessed according to local policy and procedures. It is the nurse’s responsibility to ensure their practice remains up to date and reflects the latest evidence

Published online: 15 March 2021

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5 Nursing Narrative Note Examples + How to Write

One of the most important lessons nursing students learn is the importance of documentation. Whether you are a nursing student or a seasoned nurse, knowing how to create accurate nurses' notes is vital. Narrative nurses' notes are one of the most popular forms of nursing documentation. Perhaps you are wondering how to write a nursing narrative note? In this article, I will share 5 nursing narrative note examples + how to write them and discuss the importance of accurate charting.

What Is A Nursing Narrative Note?

Featured online msn programs, what is the purpose of writing a nursing narrative note, what is the difference between a nursing narrative note and a nursing progress note, 3 advantages of nursing narrative notes, 3 disadvantages of nursing narrative notes, what elements should be included in a nursing narrative note, • date and time:, • the patient’s name:, • subjective data:, • objective data:, • assessment:, • interventions:, • evaluation:, what elements should not be included in a nursing narrative note, 1. symptoms without intervention:, 2. speculations:, 3. non-descriptive or non-precise terminology:, 4. premature charting:, 5. personal information about the patient’s family or loved ones:, how to write a nursing narrative note, 1. stay on point and be specific, 2. state the facts, 3. note presentation, 4. note objective data, 5. record subjective data, 6. make notes regarding your assessment, 7. record any medication you administer or treatment you perform, 8. did you have to include interdisciplinary team members, 9. don’t forget to sign each entry of your note with your name and credentials, what are some excellent examples of nursing narrative notes, example #1: head-to-toe admission assessment narrative note for patient admitted with recent cerebrovascular accident (cva), example #2: assessment of nursing home resident, example #3: nursing narrative note example for patient recently admitted and found on hospital floor, example #4: patient with complaints of left knee pain, example #5: patient complaint of nausea, prn medication administered, bonus 6 expert tips for writing an excellent nursing narrative note, 1. document nursing actions immediately., 2. keep documentation descriptive., 3. be objective., 4. add new information anytime it is necessary., 5. convey enough information to get your point across., 6. make sure your handwriting is legible., my final thoughts, frequently asked questions answered by our expert, 1. who can write a nursing narrative note, 2. when to write a nursing narrative note, 3. can i use abbreviations in a nursing narrative note, 4. what tense do you write a nursing narrative note, 5. are nursing narrative notes handwritten or printed, 6. how to sign off a nursing narrative note, 7. what happens if i forget to write a narrative note in the time it should have been written, 8. should i write about a patient crying in my nursing narrative note, 9. how to note pulses on a nursing narrative note, 10. how to describe lab results in a nursing narrative note, 11. can a nursing student write a nursing narrative note, 12. what are the common mistakes nurses make when writing narrative notes.

Why Is Documentation Important in Nursing?

When a nurse is busy with a busy working day and many urgent demands on her time, keeping nursing records may seem like a distraction from the actual work of nursing: looking after your patients.

Nursing is a profession that requires the ability to care for patients and documents and communicate their treatments. A nurse in any setting needs to accurately document what they have done so that others who work with them are aware of all interventions.

In reality, keeping good records is part of the nursing care they provide for their patients. It is almost impossible for them to remember everything they do and everything that happens during a shift. If each patient’s nursing record is incomplete before the transfer, it will negatively impact their wellbeing.

The Documentation provides evidence-based information which can be used for future reference and research purposes. You must understand why documentation is important in nursing to provide comprehensive care for your patients. Because of this, we are sharing this complete guide.

Protecting Nurses

What is documentation.

Documentation is a necessity in almost every profession, but it has become a vital component of every employee’s role in health care. 

It is essential to document every step of the process, from the time medication is given by a nurse to recording refrigerator temperatures by the head cook. Documentation helps to ensure routines are followed and fosters communication among staff in the same and different disciplines. 

Documentation in nursing is crucial for patients’ continuity of care, determining clinical reimbursement, avoiding malpractice, and facilitating communication between rotating providers.

In simple words, Documentation is a record of a nationally organized account of the facts and observations about a particular subject. As nurses, they must document their patient’s daily progress to provide for continuity of care.

When Documentation is not done correctly, it can lead to possible lawsuits if there was an error or negligence on behalf of the nurse that led up to something wrong happening with their patient.

Why Should You Be Documenting?

You have to keep a record of everything to go back and refer to it in case of any questions. You are also protecting your nurses by documenting all interactions with patients when they have visitors, new orders for care, or anything that may be important.

Suppose the nurse ever suffers a medical emergency and their condition is not known because they failed to document everything. In that case, nobody will know how long ago this happened, which could result in other health complications down the line.

The main point is documentation protects nurses as well as patients, so make sure there’s an easy way to keep track.

Also, this protects nurses as well; with proper documentation, they can’t be blamed for things they didn’t do or said incorrectly. Hospitals also benefit from having records on hand because if someone were ever to sue them, or a nurse for malpractice , they prove medical mistakes did or did not occur.

Otherwise, by presenting their documented notes that show where and when errors may have happened, nursing students learn better when teachers use examples from real-life experiences since these are ones that you have to record.

What Kind of Information Do You Record?

In the nursing profession, every step you take is significant for a patient’s life and your own. That is why it is necessary to keep track of all the information you gathered about a patient, the medication they are taking, etc. You should also record any changes in their condition with time so that if anything happens, you can refer back to old records for help or diagnose them again.

In today’s world, where everything is being digitized and transferred from one place to another virtually, many new devices are coming out every day, which makes recording much more straightforward.

One such device would be an electronic health records system (EHR). It makes your work easier because you no longer need paper charts at the nurse’s stations anymore.

But although EHRs save the nurse some trouble by providing an overview of data like blood pressure and heart rate, it can also be quite dangerous because there is no way to tell who may have accessed the data.

How does having proper records help your patients? 

Now it comes to the main point about how keeping documentation can help you.  The well-documented records can help you to identify the patterns of your patient’s health. It also helps in providing a clear picture of their mental status and physical condition. This way, it becomes much easier for you to work on preventive as well as curative measures.

The documented recordings do not only help to keep your patients healthy, but they even help you in getting an idea about how others’ care is going on with them, i.e., what changes have been happening since when.

The best thing about having proper Documentation is that now there will be no discrepancies between different healthcare providers’ notes because every detail has been recorded correctly, and everyone knows where everything belongs.

Benefits of creating Documentation in Nursing

When we talk about benefits, it could be following:

• Reducing the chance of malpractice lawsuits,
• It is ensuring patient safety through accurate and complete Documentation.
• Record of medicines and treatments given to patients
• Improves the quality of care provided by hospitals.
• Allows for better communication with other healthcare providers and staff in a hospital setting
• Safety measure

The most important reason we should keep records is to ensure that there is a record of what was done if something goes wrong or somebody needs it. It can be used as evidence during legal proceedings, such as malpractice lawsuits or court cases.

This is a significant undertaking that requires accuracy and completeness when documenting patient treatment. 

Patients are also protected if their medical records exist in electronic format because they provide proof regarding medications administered to them without needing the original containers to validate this information.

Recordkeeping allows physicians to communicate more effectively with other healthcare providers and staff within a hospital setting; it improves the overall quality of care delivered at hospitals, minimizes risk through accurate Documentation, facilitates continuity of care among healthcare personnel.

Conclusion on Why Is Documentation Important in Nursing

Documentation is a critical part of the healthcare field. It’s an opportunity to create and maintain records used as evidence in patient care, research, education, or legal proceedings.

By understanding what makes good nursing documentation so valuable to professionals and patients alike, you can better prepare yourself for your career and improve people’s quality of life.

More Resources

• Meaningful Use and the Continuity of Care Document
• Why Is the Nursing Process Important?
• Are Nurse’s Notes Becoming a Lost Art?
• Top Medical Abbreviations and Short Hand Fresh RN

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• Research note
• Open access
• Published: 23 September 2019

Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia

• Hagos Tasew   ORCID: orcid.org/0000-0002-0886-815X 1 ,
• Teklewoini Mariye 1 &
• Girmay Teklay 1  

BMC Research Notes volume  12 , Article number:  612 ( 2019 ) Cite this article

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Metrics details

The objective of this study was to investigate documentation practice and factors affecting documentation practice among nurses working in public hospital of Tigray region, Ethiopia.

In this study, there were 317 participants with 99.7% response rate. The result of this study shows that practice nursing care documentation was inadequate (47.8%). Inadequacy of documenting sheets AOR = 3.271, 95% CI (1.125, 23.704), inadequacy of time AOR = 2.205, 95% CI (1.101, 3.413) and with operational standard of nursing documentation AOR = 2.015, 95% CI (1.205, 3.70) were significantly associated with practice of nursing care documentation. To conclude, more than half of nurses were not documented their nursing care. Employing institutions should provide training on documentation of nursing care to enhance knowledge and create awareness on nurses’ documentation to nursing directors and chief executive officer to access adequate documenting supplies besides employing more nurses.

Introduction

Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse [ 1 ]. Nursing documentation is the principal clinical information source to meet legal and professional requirements [ 2 ]. It is a vital component of safe, ethical and effective nursing practice whether done manually or electronically [ 3 ]. Nursing documentation should fulfill the legal requirements of nursing care documentation [ 4 ].

According to a survey done by WHO it has been shown that poor communication between health care professionals is one factor for medical errors [ 5 ]. There are also evidence indicating that nursing documentation has relationship with patient mortality [ 6 ]. Although keeping a patient record is part of their professional obligation, many studies identified deficiencies in practice of documentation among nurses across the globe [ 7 , 8 ]. It has been reported that nursing records are often incomplete [ 8 , 9 ], lacked accuracy and had poor quality [ 10 , 11 ]. The challenges for documentation reported so far, include shortage of staff [ 12 , 13 ], inadequate knowledge concerning the importance of documentation [ 12 , 13 , 14 , 15 ], patient load [ 12 , 14 ], lack of in-service training [ 14 , 15 ] and lack of support from nursing leadership [ 12 ].

As a remedy for these, many researchers recommended to use a multidisciplinary approach like to develop policies and guidelines on nursing care documentation [ 12 , 13 , 15 ] and provide sustained continuing training opportunities for nurses on effectiveness of documentation [ 7 , 12 , 13 , 16 , 17 ]. The nursing leaders are also expected to support, motivate [ 12 , 17 ] and increase the number of staffs [ 15 ] for a better documentation practice.

Studies from South Africa and Ugandan reported deficiency in attitudes, knowledge and practice behaviors [ 17 , 18 ]. The studies done in Kenya and Ghana also evidenced lack of standardized method and insufficient information of nursing documentation [ 12 , 13 ]. In Ethiopia, inadequacy of data collection with lack of quality was found to be a problem [ 18 , 19 , 20 , 21 ]. The objective of the study was to assess nursing documentation practice and associated factors of nursing documentation practice in public hospitals of Tigray, Ethiopia.

A quantitative descriptive cross-sectional study design was used. The study was conducted from November 1–17, 2017. The source population for this study were all nurses who are working in government owned hospitals of Tigray region. Sample size was determined formula taking the proportion as 37.4% from previous study conducted in Northern Amhara region public hospital [ 14 ], 95% confidence interval (CI), and 5% margin of error. The final sample size was 317. Selection of hospitals for the study was carried out using simple random sampling after all hospitals in the region was identified. The study participants were selected based on the lottery method and the numbers of samples in each hospital were selected according to proportional allocation formula.

Nurses working in inpatient wards and outpatient departments; nurses having work status as a professional nurse at least for 6 months and those who were voluntary to participate were included in the study.

A structured self-administered questionnaire was developed to collect data regarding nursing documentation practice and its associated factors. Practice and knowledge of nursing documentation questions were developed based on the national guideline prepared by the FMOH (EHRIG), various books written on nursing documentation and literatures related to the topic [ 14 , 15 , 22 , 23 ].

Prior to the actual data collection, the items were pre-tested with 5% (16 samples) of the total sample size of nurses working in Adwa hospital with self-administer questionnaire and the results were used to check reliability, consistency and completeness of the questionnaire and some improvements were done on the wordings. Reliability of the questioner was checked using Cronbach alpha (0.79).

Documentation practice

Practice of study participants measured using 10 multiple-choice items. A value of 3, 2, 1 and zero was scored for “always”, “sometimes”, “rarely” and “never” options respectively. For questions in which there were multiple correct and incorrect responses (n = 8), the scoring system used the proportion of correct responses [ 15 ].

Knowledge of documentation

The knowledge of study participants measured using 10 items with multiple options and scoring based on a number of responses given in each question. A value of 1 and 0 was scored for “yes” and “no and I don’t know” options respectively.

The attitude of practice

Attitude of the study participants measured by using the Likert scale questions with 10 items.

The collected data were checked for completion and cleaned manually then the data were entered into computer by SPSS version 22 software was used both for data entry and for analysis. Descriptive statistics like mean, frequency and percentage. Binary logistic regression was used for inferential statistics. Bi-variable and multivariable logistic regression were applied to measure strength of association.

Good practice

Those respondents who scored above or equal to the mean score of practice questions.

Good knowledge

Those respondents who scored above or equal to the mean score of knowledge questions [ 14 ].

Favorable attitude

Those respondents who scored above or equal to the mean score of attitude questions [ 14 ].

Socio-demographic characteristics of respondents

A 317 respondents participated in this study out of which 316 returned the questionnaires made the response rate 99.7%. From 316 nurses who participated in this study, 207 (65.5%) were females and 109 (34.5%) were males. Two hundred eight (65.5%) fall within the ranges of 25–34 years age group. Most of the respondents were holding bachelor degree 279 (88.3%). One hundred two (48.1%) of them were senior nurse professionals while 148 (46.8%) were junior nurse professionals and 11 (5.1%) were junior clinical nurses. One third of the participants were worked as a nurse for 2–5 years when 107 (33.9%) and 100 (31.6%) of them worked for more than 5 years and less than 2 years respectively ( Table  1 ).

Practice of nurses towards nursing documentation practice

A total of 10 multiple option questions were used that had a potential score of 12 and the mean score was 7.26 (S.D ± 2.03). For this study, participant performance was categorized into good and poor practice with scores 7.26 (mean value) or above as good, while those below the mean score as having poor practice. One hundred fifty-one (47.8%) of the respondents scored to have good practice and the rest 165 (52.2%) of the study subjects scored below the mean.

Among all nurses, 230 (72.8%) of them check nursing notes written by their colleagues from which most 130 (56.5%) said the notes are incomplete. Concerning the system of documentation, majority 262 (82.2%) of them denied for application of computerized nursing documentation in their hospital. Regarding the practice of patient care documentation, most 165 (52.2%) of the respondents had poor nursing documentation practice (Table  2 ).

Knowledge of respondents towards nursing documentation

A total of 10 multiple choice questions were used to measure the knowledge of respondents regarding nursing documentation and the mean score was 4.9 (SD ± 1.9). The minimum score was 1.5 and the maximum 9. The total mean score for knowledge questions was 4.9. Of all the respondents, 136 (43%) subjects scored above or equal to the mean value and the rest 180 (57%) of them scored below the mean. One hundred eighty (57%) of the respondents were found to have poor knowledge of documentation.

Attitude of respondents towards nursing documentation

Participants’ attitudes were assessed via a Likert scale, with item scores ranging from strongly agree (5) to strongly disagree (1) which had a potential score of 50. The total mean score for attitude was 42 (S.D ± 4.9) and scores greater or equal to the mean was categorized as favorable and unfavorable for scores below the mean. In this study the overall attitude score of the study participants showed that above half of respondents 176 (55.7%) had favorable attitude and the remaining 140 (44.3%) had unfavorable attitude.

Reason for poor nursing care documentation practice

Out of the 128 (40.5%) of respondents who do not document every care provided to a patient. Most 65 (41.9%) of them reported their reason to be lack of time followed by shortage of documenting sheets, inadequate staff, lack of motivation from supervisors and lack of obligation from employing institution by 38 (24.5%), 28 (18.1%), 17 (11%) and 7 (4.5%) respectively.

Factor associated with documentation practice of nursing care plan

Using binary logistic regression, crude odds ratio with 95% confidence interval was calculated to determine statistical significance and strength of association between each variable. Variables having a p value < 0.25 in the bivariate logistic analysis were entered into the multivariable logistic analysis and adjusted odds ratios were then calculated to investigate association with controlled confounding variables.

According to finding of this study, those nurses who are unfamiliar with operational standard of the nursing documentation were two times more likely to have poor nursing documentation practice than those who are familiar (AOR = 2.015, 95% CI 1.205, 3.370). Additionally, lacked time and those who lacked documentation sheets were two times [AOR = 2.205, 95% CI (1.101, 3.413)] and three times [AOR = 3.271, 95% CI (1.125, 23.704)] more likely to perform poor nursing documentation when compared to those with adequate time and adequate documenting sheets respectively (Table  3 ).

This cross-sectional study aimed to investigate nursing documentation practice and associated factors among nurses in public hospitals of Tigray, Ethiopia.

The finding of this study showed that familiarity with operational standard of nursing documentation, lack of time and inadequacy of documenting sheets had a significant effect on nursing care documentation practice.

The result of this study shows that practice nursing care documentation was inadequate (47.8%) among nurses similar to Nigeria [ 24 ] where both the documentation practice and knowledge were found to be insufficient. This finding is higher from Indonesia 33.3% [ 23 ] and University of Gondar hospital (37.4%) [ 14 ]. This discrepancy might be due to difference in the study period since there might be information difference with time gap because the studies were done before 2 years and after technology had faster growth like smart care introduced in most hospitals of Ethiopia. The other reason could be nurses educational development variation across the countries [ 25 ]. Most (52.2%) of the study participants in this study revealed poor nursing documentation practice which coincides with a study done in Felege Hiwot referral hospital (87.5%) [ 19 ] where medication administration errors were due to nursing documentation error [ 19 ]. This finding is lower than a finding from South Africa 68.3% [ 22 ] and Nigeria 70% [ 15 ]. This might be due to insufficient knowledge as indicated in those studies favorability of the working environment and organizational structure.

Some barriers have been identified to hinder the nursing documentation practice in this study. Those nurses who are familiar with the availability operational standard of nursing documentation were two times more likely to document their care compared to the unfamiliar ones. Similarly, lack of time and scarcity of sheet were leading factors that negatively influence the nursing documentation practice in this study. Respondents who had lack of time were two times more likely to document (41.9%) similar to a study conducted in Nigeria (41.7%) [ 15 ] and England (47%).

Despite its non-significant association, knowledge has shown association with documentation practice in other studies. The knowledge level of participants was 43% in this study which contradicts with the finding from University of Gondar hospital (58.3%) [ 14 ], South Africa (74.9%) [ 22 ], Iraq (59%) [ 16 ] and Indonesia (82.7%) [ 23 ].These inconsistencies might be related to socio demographic variability of the study participants or difference in familiarity to the documentation guideline [ 14 ].

Conclusions

Nursing care documentation practice was poor among nurses. Inadequacy of documenting sheets, lack of time and familiarity with operational standard of nursing documentation were factors associated with nursing care documentation practice. The following recommendation should forward to the healthcare facilities:

Provide a training program to enhance the knowledge of nurses and to familiarize them with institutional policy regarding documentation and provide adequate documentation materials.

Limitations

Since this study is based on self-reported data, most of the variables might have been exposed for social desirability bias.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

adjusted odd ratio

confidence interval

Federal Ministry of Health

inter quartile range

Statistical Package for Social Sciences

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Acknowledgements

The authors wish to acknowledge the nurses who helped immensely in data collection and study participants.

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Hagos Tasew, Teklewoini Mariye & Girmay Teklay

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HT: Conceived the study, designed questionnaire, data collection, directed data analysis. All authors participated in questionnaire design, data collection, data analysis, manuscript writing. All authors read and approved the final manuscript.

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Ethical clearance was obtained from the Institutional Review Board (IRB) of Aksum University (AKU), College of Health Sciences, Department of Nursing. Official letter was Obtained to acquire permission from administrations of the selected hospitals. Approvals were obtained from the participating hospitals to administer the questionnaire to the concerned population and a written consent was obtained from each respondent, explaining the aims and objectives of the research. Confidentiality was ensured as well during the course of the study.

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Tasew, H., Mariye, T. & Teklay, G. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Res Notes 12 , 612 (2019). https://doi.org/10.1186/s13104-019-4661-x

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Received : 22 January 2019

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DOI : https://doi.org/10.1186/s13104-019-4661-x

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Nursing Documentation Essay

Type of paper: Essay

Topic: Nursing , Breastfeeding , Information , Focus , Soap , Patient , Nurse , Decision Making

Published: 11/18/2021

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Nursing documentation plays a big role towards not only achieving efficiency in management of patients, but also assisting in accurate decision making among the nursing staff. Among the most common methods of documentation practiced around the world include SOAP/SOAPIER and focus charting. Both of these documentation methods are problem-oriented where the nurse begins by identifying the problems that the patient presented with. While focus charting narrows down to the behavioral concerns of the patient such as a decreasing urinary output in a specific duration, SOAP/SOAPIER, the nurse systematically lists all the problems in a more conclusive manner. Focus charting has three components which are data, action and response. On the other hand, SOAP/SOAPIER has subjective information which highlights the symptoms, objective information highlighting the signs, assessment data, plan, implementation and finally revision (Treas & Wilkinson, 2013).

Focus charting as a method of documentation has its advantages and disadvantages. Its advantages include:

It is compatible with most uses of the nursing processes. This means that it is able to meet the necessary demands of documentation by nurses. It saves on time by using more than one checklists by nurses. Every nurse can use their own check list without having to look at those created by other nurses since it is updated regularly.

Its shortcomings include:

It is unable to chart while adhering to the nursing diagnoses as well as the expected outcomes. It does not offer solutions in the event that the problems of patients are missed due to insufficient database. On the other hand, the advantages of SOAP/SOAPIER include: It is able to provide for the continuity of communication and care by keeping all the necessary information in one place (Marrelli & Harper, 2000).

It reinforces the use of the nursing process by enhancing the process of decision making.

Among its disadvantages are: Inability to track the trends in the status of the patient. It may result in a loss of chronology of charting because more number of sheets are required. Focus charting and SOAP/SOAPIER can be used interchangeably depending on the facility. This is because both serve as adjunct to document the routine, observations and other assessments of a patient.

Marrelli, T. M., & Harper, D. S. (2000). Nursing documentation handbook. St. Louis: Mosby. Treas, L. S., & Wilkinson, J. M. (2013). Basic nursing : concepts, skills, & reasoning. Philadelphia: F.A. Davis.

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Factors Influencing Writing Completeness of Nursing Documentation a Literature Review

2021, INFLUENCE : International Journal of Science Review

The quality of service at the hospital can be seen from the implementation of nursing care documentation. Documentation is useful for hospitals in improving accreditation standards/JCI (Joint Commission International) as a communication tool between professions, quality service indicators, evidence of nurse responsibility and accountability, data sources and as a research tool. Nursing care documentation is carried out as evidence of nursing actions taken professionally and legally so as to provide protection to nurses and patients. The method used in writing this article is a Literature Review through several stages, namely making questions, identification, eligibility, selection of article inclusion and screening. The selection process is stated in the literature review framework and the results of 8 articles from national and international journals are obtained. From the results of a review of journals conducted, it shows that almost all studies conducted have the same results re...

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