Irfan Ullah Khattak, Tania Zaman, Shaheen Ghani


Introduction: Nursing Documentation is a crucial part of the nursing process as it is the essential way of communication within the health care team regarding patient care. Nurses’ knowledge about documentation is important as it is a legal requirement and main responsibility of nursing staff.

Materials & Methods: A survey of nurses was conducted in three government tertiary care hospitals of Peshawar, Khyber Pakhtunkhwa. Data were collected through a designed questionnaire from 300 staff nurses regarding demography profile, knowledge and practice about nursing documentation. Data analysis for descriptive statistics was done through   SPSS 17.

Results: Overall, 180 (60%) nurses reported that nursing documentation means handling and taking over patients’ charts, 66% reported that is vital signs record, 53% nurses confirmed that it is the legal safety of nurses to maintain documentation, 40% nurses reported that nursing documentation is normal and abnormal findings of patient labs and reports; only 19% nurses maintained documentation and 43% claimed the lack of check and balance as the reason why they do not maintain documentation. Only 12% of nursing staff were satisfied with their nursing documentation. Less than half (42%) of the nurses were in favour of education programs on nursing documentation.

Conclusion: There is need for strict check and balance and nurses should be trained by organizing seminars and teaching session on nursing documentation. Electronic documentation may be a way to improve the standard of nursing documentation.

Keywords: Nurses; Nursing Staff; Knowledge; Documentation.

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