Abstract:
Background: Nursing documentation is the process of recording of nursing care given to
individual clients to have an account of what happened and when it happened. It has a vital part
in education, research, meeting legal and professional practice standards beside its invaluable
role in communicating patient information to assure effective, safe, quality, evidence-based and
individualized care. Inappropriate documentation is a key factor in a care that is delayed, omitted
or repeated, fragmented and full of clinical mishaps. Despite of this, in Ethioppia there is a
paucity of information on nursing documentation practice and its associated factors. Studies were
limited only in one hospital besides the practice level determined through self-reported question.
Objective: The aim of this study was to assess documentation practice and identify its associated
factors among nurses in Harari Regional State and Dire Dawa City Administration Governmental
Hospitals, Eastern Ethiopia from March 10-25/ 2019.
Methods: Institutional based Quantitative cross-sectional study was conducted among 430
nurses supported by retrospective review of 421 medical records. Simple random sampling was
employed for the selection of each participant after the total sample size had allocated
proportionally for each hospital. Data were collected by using self-administered questionnaire
and review of records. After it had collected data were checked, coded and entered in to Epi data
version 3.1 and exported to statistical package for social sciences version 20.0 for analysis.
Results: In this study, 38.5% (95%CI 34%-43.2%) of medical records were found to had good
nursing documentation practices. Self-reported documentation practice (47.9%) was used to
identify factors and nurses age above 35 years, favorable attitude, in-service training, adequate
nurse to patient ratio, availability of motivation from supervisors and familiarity with operational
standards of nursing documentationwere found to had statistically significant positive association
with documentation practice with AOR and 95%CI of 3.54 (1.170-10.8), 5.66 (3.17- 10.11),
2.53(1.477-4.35), 2.24(1.24-4.047), 4.60 (2.721-7.76) and 1.98 (1.137-3.44) respectively.
Conclusions: Documentation practice was low. Attitude, training, familiarity with standards,
availability of motivation, nurse to patient ratio and age were independent factors. So it is better
to put further effort towards improving documentation practice through providing training on
standards of documentation and enhancing favorable attitude of nurses towards documentation
by motivating them for their documentation activities
