ABSTRACT

Descriptive study was conducted to assess the knowledge and practices of nurses regarding documentation of patient care. The objectives of the study were 1. To assess the knowledge of nurses regarding documentation of patient care. 2. To assess the practices of nurses regarding documentation of patient care. 3. To find the association between knowledge of nurses with regard to documentation of patient care and selected variables. 4. To find the association between practice of nurses with regard to documentation of patient care and selected demographic variables. 5. To correlate the knowledge and practices of nurses with regard to documentation of patient care. Population for the study were the nurses who were working at NIMS, Hyderabad. The sample size was 100 which was selected by non-probability simple random sampling technique. The conceptual framework used for the study was based on wiedenbachs helping art of clinical nursing theory. Each nurses knowledge was assessed by self-instruction questionnaire and retrospective check list. The instruments were evaluated for content validity. The reliability of the tool was tested by split half method among 10 samples. The r value was calculated to be r = 0.88 for knowledge and r = 0.93 for practices. The questionnaire and check list was found reliable. Pilot study was conducted at NIMS among 10 samples (samples were not included in actual study). The tool was found to be feasible, practicable and appropriate to conduct final study. Data for the main study was conducted on 13-8-2013 to 12-9-2013 at NIMS, Hyderabad, from nurses working at NIMS, who fulfilled the criteria for selection. Data was analyzed by SPSS software using descriptive and inferential statistics. The results reveled that there was significant relationship between the knowledge of nurses and their age, sex, professional qualification,

designation, total years of work experience, current area of work experience, attending in-service education program and factors that facilitate documentation of patient care and current area of work experience was found to be associated with practice of nurses with regard to documentation of patient care it was computed using chi- square test. The sample characteristics of the study revealed that out of 100 samples 51.0 % of nurses are from the age group of 21-30 years, 96.0% are females, 51.0% were with professional qualification of GNM course, 27.0% were head nurses, 38.0% belong to 1-5 years of work experience, 35.0% belong to intensive care unit, and 63.0% have not been participated in in-service education program on documentation. The finding revealed that 64% nurses have average knowledge, 30% have above average score and 6% nurses showed below average levels of knowledge in documentation of patient care. 61% nurses scored average for practice, 39% scored below average and none scored above average for practice levels in documentation of patient care. The calculated Pearsons correlation r value (r = 0.149) and hence the probability value (r = 0.139) which is greater than 0.05 level of significance, hence there is a positive correlation between the mean knowledge and practices but it is not significant. The findings of the study had shown that there was gap between the knowledge and practices of nurses regarding documentation of patient care. Nurses should take the responsibility to improve their documentation skills, and use of advanced technology like use of computer operating systems for documentation. They require additional learning inputs to improve their knowledge levels and practices in the form of in-service education programs, and conducting workshops. Curriculum should emphasis more on completing the kardex, nurses notes, and most importantly documentation of actual or potential health care needs of patients. Young researchers can conduct further studies by taking up a single aspect of documentation of patient care. Key words: knowledge, practices, documentation of patient care, nurses.