FACTORS INFLUENCING DOCUMENTATION OF TREATMENT AMONG NURSES AT SOROTI REGIONAL REFERRAL HOSPITAL-SOROTI CITY. A CROSS-SECTIONAL STUDY.

Authors

  • Rose Mary Awino Soroti School of Comprehensive Nursing
  • Charles Ayen Owiny Soroti School of Comprehensive Nursing
  • Gabriel Abongo Soroti School of Comprehensive Nursing
  • Patricia Pita Soroti School of Comprehensive Nursing
  • Derick Modi Faculty of public health, Community health department, Lira University.

DOI:

https://doi.org/10.71020/jwhr.v2i5.23

Keywords:

Documentation of Treatment, Nurses, Soroti Regional Referral Hospital, Soroti City

Abstract

Background

Nursing documentation reflects the entire process of providing direct nursing care to patients. Nursing documentation that is clear, accessible, and accurate is an essential element of quality, safe, and evidence-based nursing care. The study aimed to identify factors influencing the documentation of treatment among nurses at Soroti Regional Referral Hospital.

Methodology

The researcher used a descriptive cross-sectional study employing quantitative techniques of data collection and a total of 30 nurses working in different wards at SRRH were selected using the purposive sampling method. Data was analyzed by Microsoft Excel and presented in tables, pie charts, and tables.

Results

30 respondents participated in this study, 22 females and 8 males. The majority of the respondents were 25-29 years old, while those between 20-24 and 30-35 years old were the minority. The study found that 93.3% of nurses did not document patient care, 93.3% did not have the necessary documentation materials, and 60% of the nurses reported working alone in a shift.

Conclusion

Inadequate essential documentation materials and a low number of nurses working per shift were found as the major reasons for poor documentation of treatment among nurses in SRRH.

Recommendation

The hospital administration should provide adequate documentation materials and lobby for more nurses to boost the number of those currently employed at the facility.

Author Biographies

Rose Mary Awino, Soroti School of Comprehensive Nursing

Rose Mary Awino holds a diploma in comprehensive nursing, from  Soroti School of Comprehensive Nursing.

Charles Ayen Owiny, Soroti School of Comprehensive Nursing

Charles Ayen Owiny, tutor at Soroti School of Comprehensive Nursing

Gabriel Abongo, Soroti School of Comprehensive Nursing

Gabriel Abongo holds a diploma in comprehensive nursing, from Soroti School of Comprehensive Nursing.

Patricia Pita, Soroti School of Comprehensive Nursing

Patricia Pita holds a diploma in comprehensive nursing from Soroti School of  Comprehensive Nursing.

Derick Modi, Faculty of public health, Community health department, Lira University.

Derick Modi, holds a bachelor's degree of science in Public Health, from Lira University School of Public Health.

References

Asamani, J. A., Amenorpe, F. D., Babanawo, F., Maria, A., & Ofei, A. (2015). of inpatient care in eastern Ghana. British Journal of Nursing, 23(1),4854.https://doi.org/10.12968/bjon.2014.23.1.48

Aseratie M., Murugan R. & Molla M, (2014), 'Assessment of factors affecting the implementation of nursing process among nurses in selected governmental hospitals, Addis Ababa, Ethiopia; Cross-Sectional Study', Journal of Nursing Care 3(1), 170 10.4172/2167-1168.1000170

Avoka Asamani J, Delasi Amenorpe F, Babanawo F,(2014).Nursing documentation of inpatient care in eastern Ghana. Br J Nurs 2014;23:48-54. 10.12968/bjon.2014.23.1.48 https://doi.org/10.12968/bjon.2014.23.1.48

Beshir MA, Endehabtu BF, Tilahun B, Guadie HA, Awol SM,(2023) Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region. Ethiopia 2021. 2022;22(1):1-13. https://doi.org/10.1186/s12913-022-07809-6

Bijani, M., Sadeghzadeh, M., KhaniJeihooni, A., & Hannan, K.S. (2016). Factors influencing poor nursing documentation from the perspective of nursing staff. International Journal of Medical Research and Health Sciences, 5, 717-718.

De Groot K, De Veer AJE, Paans W, Francke AL (2020). Use of electronic health records about standardized terminologies: a nationwide survey of nursing staff experiences. Int J Nurs Stud.2020;104:103523. https://doi.org/10.1016/j.ijnurstu.2020.103523.

Duclos-Miller P. A. (2016). Improving nursing documentation and reducing risk.

Feleke SA, Mulatu MA, Yesmaw YS (2015) . Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC Nurs 2015;14:53. 10.1186/s12912-015-0099-1 https://doi.org/10.1186/s12912-015-0099-1

Gilson L,(2014), Implementation of a new birth record in three hospitals in Jordan: A study in health system improvement, viewed 28 April 2018,fromhttp://www.who.int/countries/jor/en/.

Hailu H. (2017) Assessment of Self-Reported Practice of Nursing Documentation and Associated Factors among Nurses in Selected Public Hospitals, Addis Ababa, Ethiopia, 2017: Addis Ababa University; 2017. https://doi.org/10.5772/intechopen.100559

Kebede M, Endris Y, Zegeye DT.(2017) Nursing care documentation practice: the unfinished task of nursing care in the University of Gondar Hospital. Inform Health Soc Care 2017;42:290-302. https://doi.org/10.1080/17538157.2016.1252766

Krishna R, Khyati G. (2017) Nursing errors in the documentation: a review. Ruas- Uas JMC 2017;3:1-5. [Google Scholar]

McCarthy B, Fitzgerald S, O'Shea M, Condon C, Hartnett-Collins G, Clancy M,(2019) Electronic nursing documentation interventions to promote or improve patient safety and quality care: a systematic review. J Nurs Manag. 2019;27(3):491-501. https://doi.org/10.1111/jonm.12727.

Mutshatshi TE, Mothiba TM, Mamogobo PM, Mbombi MO (2018) Record-keeping: challenges experienced by nurses in selected public hospitals. Curationis. 2018;41(1):1-6. https://doi.org/10.4102/curationis.v41i1.1931

Nakate, G.M., Dahl, D., Petrucka, P., Drake, K. and Dunlap, R. (2015) The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital. Open Journal of Nursing, 5, 1063-1071. http://dx.doi.org/10.4236/ojn.2015.512113

Oseni OM, Adejumo PO. (2014) Nurses' reported practice and knowledge of wound assessment, assessment tools, and documentation in a selected hospital in Lagos, Nigeria. Afr J Med Med Sci 2014;43:149-57. [PubMed]

Saiva A. I. (2022) The perils of poor documentation. 2022. https://saiva.ai/the- perils-of-poor-documentation/

Tamir, T., Geda, B., & Mengistie, B. (2021). Documentation Practice and Associated Factors Among Nurses in Harari Regional State and Dire Dawa Administration Governmental Hospitals, Eastern Ethiopia. Advances in Medical Education and Practice, 12, 453-462. https://doi.org/10.2147/AMEP.S298675

Tubaishat A, Habiballah L. (2016) eHealth literacy among undergraduate nursing students. Nurse Educ Today. 2016;42:47-52. doi: 10.1016/j.nedt.2016.04.003. [PubMed] [CrossRef] [Google Scholar https://doi.org/10.1016/j.nedt.2016.04.003

Wanyama, A., Kaddumukasa, M., & Atukunda, E. (2020). Assessment of Nursing Documentation Practices and Challenges Among Nursing Students in Uganda. Journal of Nursing Education and Practice, 10(10), 168-174.

Wilbanks B. A., Geisz-Everson M., Boust R. R. (2016). The role of documentation quality in anesthesia-related closed claims: A descriptive qualitative study. Computers, informatics, nursing: CIN, 34(9), 406- https://doi.org/10.1097/CIN.0000000000000270

Downloads

Published

2025-05-30

How to Cite

Awino , R., Owiny, C. A., Abongo, G., Pita, P., & Modi, D. (2025). FACTORS INFLUENCING DOCUMENTATION OF TREATMENT AMONG NURSES AT SOROTI REGIONAL REFERRAL HOSPITAL-SOROTI CITY. A CROSS-SECTIONAL STUDY. Journal of World Health Research, 2(5), 11. https://doi.org/10.71020/jwhr.v2i5.23

Issue

Section

Section of orginal Peer-reviewed articles

Similar Articles

<< < 1 2 3 4 5 > >> 

You may also start an advanced similarity search for this article.

Most read articles by the same author(s)