Knowledge, Attitude and Practices Towards Documentation Among Nurses at Uganda Heart Institute, Mulago National Referral Hospital.

Abstract

Documentation serves three purposes; facilitates communication, it promotes safe and appropriate nursing care; and meets professional and legal standards (WHO, 2015). The study assessed the level of knowledge, attitude and practices among Nurses towards documentation in Uganda Heart Institute, Mulago National Referral Hospital. Descriptive research design was used where a sample of 72 respondents who were nurses was used and was selected by simple random sampling and data was collected through questionnaires.

Findings indicated high level of knowledge about documentation among the nurses because all them correctly understood it as recorded information during communication where a significant portion learnt it during nursing training 66(92%). They correctly defined it as recorded information during communication, 63(88%) knew that it should bear; patients name, age, contact, diagnosis and treatment, 54(75%) knew that it required a lot of space, 66(92%) thought that, it was good to cross check information before storing it.

Respondents had positive attitude towards documentation where, majority 60(83%) believed documentation was not wastage of time, 61(85%) believed that all patients do not have the same information, 46(64%) believed failure of some nurses to record was not due to belief they could not forget a daily practice, 52(71%) believe that all not all patients were supposed to know what they suffered from.

Nurses had poor practices towards documentation where it was observed that, most 49(68%) did not record patient‟s information immediately after taking it from them, 68(94%) recorded information manually, 43(60%) never consulted their fellows when recording information and 50(69%) partially recorded patients information. In conclusion despite nurses being aware that documentation was vital in nursing practices as it helps to record information on diagnosis and treatment of patients, majority of nurses had good attitude since they believed that different patients had different information and they did not know what they suffered from thus need to document. They however had poor practices; where majority did not record regularly, never consulted their fellows which led to partial recording. The researcher records that; supervisors monitor and evaluate what nurses record, should record immediately after taking information from patients so that they do not forget to record wrong information.