World Journal of
Pharmaceutical and Life Sciences

ASSESSMENT OF CLINICAL DOCUMENTATIONS: A NEED FOR QUALITY NURSING CARE

Chiejina E.N. Ph.D*, Odira C.C. M.Sc and Anieche J.E. M.Sc

ABSTRACT

Nurses bear a large burden in both managing and documenting the care given to clients. The need for accountability in the nursing practice and the need for evaluating care given are paramount. This study evaluated the clinical documentations of the nursing care given to clients by the care providers in primary, secondary and tertiary health institutions. Purposive and simple random sampling techniques were used to select documented nursing actions for 264 clients. One research question and three null hypotheses guided the study. The instrument used for data collection was Checklist on Nursing Documentation in the clinical setting. Standard descriptive statistics of frequency, means and Standard Deviation were used to summarize the variables. Pearson Product moment correlation was used to answer the research question and analyses of variance (ANOVA) were adopted in testing the null hypotheses at 0.05 level of significance. Nursing documentation was noted to have significant impact on nursing science. Significant differences were also observed among the primary, secondary and third party providers accountability with regard to ensuring core principles of nursing documentation, timeliness and preciseness in documentation.

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