Assiut Scientific Nursing Journal

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DOI : 10.21608/asnj.2023.229171.1653 http://olddrji.lbp.world/indexedJournals.aspx
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Effect of Quality of Nursing Documentation on Continuity of Patient Care

Eman Thabet Ahmed1, Nahed Shawkat Abo Elmaged2, Eman Kamel Hosny3 & Karima Hosny Abdelhafez4
1.
Nursing Specialist, New valley, Egypt.
2.
Professor of Nursing Administration, Faculty of Nursing, Assiut University, Egypt.
3.
Assistant Professor of Nursing Administration, Faculty of Nursing, Assiut University, Egypt.
4.
Assistant Professor of Nursing Administration, Faculty of Nursing, Assiut University, Egypt.

Abstract:
Background: Nursing documentation is the record of nursing care that is organized and provided to specific patients
and clients by licensed nurses or other caregivers acting under a licensed nurse's supervision. Aim: To investigate the
effect of quality of nursing documentation on continuity of patient care at Elkharga general hospitals. Study design:
Descriptive correlation design was used in this study. Study setting: This study was conducted at Elkharga General
Hospital Affiliated to Ministry of Health and Population. Samples: Included two types of samples are convenient
sample of nurses working at Elkharga general hospital with total number (no=80) and patient's records and
departments records. Data collection: Data was collected using three tools adapted by the researcher1sttool Quality
of nursing documentation questionnaire. 2nd tool Concurrent auditing checklist for nurse’s records. 3rdtool continuity
of patient care checklist observation. Results: This study indicated that there was a highly statistically significant
positive correlation between quality of nursing documentation and continuity of patient care. Conclusion: There was
an accepted level of nursing documentation quality, the majority of total nurses samples had an average level of
continuity of patient care. Recommendations: Holding a workshop for the nurses on the value of nursing
documentation, as well as frequent audits, regular feedback, disciplinary action for defaulters, and rewards for high
achievers.

Keywords: Quality of nursing documentations & Continuity of patients care

Introduction: A list of the nursing care that was planned for and
Nursing documentation is crucial for nurses to provided to each patient and client by a registered
provide nursing care. This documentation is used as a nurse or by another caregiver working in accordance
reference for nursing services provided to patients with the licensing of a licensed nurse constitutes
who need records and reporting that can be used as nursing documentation. Nursing documentation
responsibility and accountability of various possible comprises assessment, nursing diagnoses,
problems experienced by patients both satisfaction interventions, implementation, and evaluation of
and dissatisfaction with the services provided progress and results in an effort to draw attention to
(Herisiyanto et al., 2020). problems that develop during the nursing process and
The largest group of healthcare workers in the data that aids in decision-making. (Abdelrahman, et
system, nurses, play a crucial role in every area of al., 2021).
performance improvement in healthcare Documentation includes any original files or
organizations. The position calls for planning patient authentic records that may be used to support a claim
treatment, keeping an eye on patient data, and or as proof in court. Nursing documentation serves as
collaborating with other multidisciplinary team evidence of the recording and reporting abilities used
members. Due of its time-consuming, repetitive, and by nurses to complete care records that are helpful to
inaccurate nature, paper-based documentation is patients, nurses, and the healthcare team in providing
thought to fall short of the criteria for high-quality health services based on precise and detailed written
documentation and provider communication. (Akhu- communication with nursing responsibilities.
Zaheya 2017). (Alqattan, et al., (2018)
Nursing documentation is crucial for nursing growth, Quality documentation of nursing care promotes
particularly the professionalization process of nursing consistency, distinctiveness, and defines the nursing
and maintaining nursing as a respectable and regarded process. By monitoring the patient's need for care and
profession in society. This is because documentation their response to nursing actions, it can also raise the
may show the quality of a given nursing treatment. standard of nursing care. Documenting the therapy
(McCarthy et al., 2019). given, the patients' reactions, and an evaluation of the

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Print Issn: 2314-8845 Online Issn: 2682-3799
Assiut Scientific Nursing Journal Ahmed et al.,

care given are all parts of effective documentation. while the researcher as an quality control member and
(Wang, 2019). her responsibility is to review the records to ensure
Nursing Documentation is a crucial aspect of accurate documentation. The researcher found
professional nursing practice. In order to provide problems in documentation at Elkharga hospital as
consistent information on the assessment, care given, inaccurate, inappropriate, incomplete and
and assessment of patient responses to care, the disorganized charts or records. That couldn't be
documentation must be accurate, current, and reliable in clinical decisions or incomplete patient
thorough (Abdelrahman, et al., 2021). care for medical and nursing personal.
An essential factor for planning nursing care is Few studies conducted this study so, the researcher
nursing documentation. Nurses are required by law to investigate effect of quality of nursing documentation
record their nursing procedures. Objectivity, on continuity of patient care.
specificity, clarity, consistency, comprehensiveness, Aim of the Study
maintaining confidentiality, and avoiding recording General objectives:
mistakes are just a few of the many criteria that Investigate the effect of quality of nursing
govern appropriate nursing documentation. documentation on continuity of patient care.
In order for parties in the hospital, such as physicians, Specific objectives:
pharmacy units, radiology units, or nurses 1. Assess the quality of nursing documentation
themselves, to use the document, it will be used to among staff nurses in Elkharga General Hospital.
identify the patient's starting state and current status. 2. Assess the continuity of patient care.
The information in the nursing document is 3. Investigate the effect of quality of nursing
admissible as evidence in court and can be utilized to documentation on continuity of patient care.
address legal issues that occur in the delivery of 4. Determine the factors affecting quality of nursing
healthcare and nursing services (Herisiyanto et al., documentation.
2020). Research Questions
All members of the health team can utilize the To fulfill the aim of the present study, the following
recording as a helpful source of information for research questions are formulated:
communication, financial statements, teaching, 1. To what extent the quality of nursing
studies, research, audits, and legal documentation documentation is attained?
(Alqattan et al., 2018). To guarantee the provision of 2. Is there a continuity of patient care?
safe and high-quality healthcare services, nursing 3. Is there a relation between quality of nursing
documentation must be completed to the highest documentation and continuity of patient care?
standard, regardless of the manner of recording 4. What are the factors affecting quality of nursing
(AbdElrahman, et al., 2021). documentation?

Significance of the Study Samples and Method

Incomplete records, incorrect patient depiction, and The study was portrayed according to the four
the labor-intensive nature of recording are just a few following designs.
examples of nursing documentation shortcomings. I. Technical design
The inability to effectively interchange and transfer II. Administrative design
information affects the continuity and quality of the III. Operational design
care provided; as a result, hospital administration, IV. Statistical design
nurses, and nursing researchers have all expressed a Technical design
desire to improve nursing documentation. Changes in This design was involved the research design, setting,
record keeping practices are frequently made to subject and data collection tools.
satisfy professional standards, reduce paperwork, and Study design:
adhere to regulatory obligations (Aldosari et al., Descriptive correlational design was used.
2018). Setting:
There are many studies internationally was done as a The present study was conducted in Elkharga General
meta-study of the essentials of quality nursing Hospital which located in The New valley
documentation and for improving quality of nursing governorate. This hospital consists of one building
documentation system in home health care setting with three floors. Bed capacity of Elkharga hospital
(Goutun & syse, 2017).on the other side many with total number (no=200 bed) included pediatric,
studies was done in Egypt as on-the job versus off Medical, General surgery, Neonate, Obstetric,
training of nurses in documentation of nursing Intensive care unit, Cardiology care unit, Dialysis
practice and training as a mean for improving staff Department. This hospital serves Elkharga city center
nurses documentation skills (Tasew et al, (2019). and eight nearby Elkharga villages. Department's

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Assiut Scientific Nursing Journal Ahmed et al.,

name: Critical care departments, nursing staff (n=45), of patient care as follow: (4) strongly agree, (3) agree,
Surgery department, nursing staff (n=20) and Medical (2) disagree, (1) strongly disagree and (0) don't know.
department, nursing staff (n=15) 2nd tool: Concurrent auditing checklist for nurses
Subjects: records for 3 months period; it was developed by
There are two types of samples included in the (Abdelrahman, 2021). It consists of two parts. It
current study. aims to assess quality of nursing documentation by
First sample is convenient sample of nurses working auditing check list.
in Elkharga general hospital with total number First part: Content of sheets as patient's demographic
(no.=80). data (patient name, age, date of admission, gender,
Second sample: the patient's records (i.e. vital signs, medical diagnosis).
fluid balance chart, nursing notes, laboratory Second part: Concurrent auditing checklist, it
investigation, shift reports, medication consists of (8dimensions) with (54 sub dimension) as
administration) all records (no.=120) of Critical, follows: vital signs record (4 items), nursing notes (1
Medical, Surgery Departments all-over three-months items), fluids balance chart (8 items), medication
period, one month for each department for the three administration record (2 items), laboratory
shifts. investigation record (4 items),contents of inter shift
Data collection tools: report(7items),and general criteria for quality of
Three tools used in the study: documentation (18 items).
1sttool: Structured self-administered questionnaire The scoring system for observed quality of nursing
which consists of two parts: - documentation: the observed items were checked
First part: Personal data developed by the researcher against two points (1) and (0) for recorded and not
to collect data related to demographic data of the staff recorded respectively.
nurses, it includes (6 items) as: age, gender, years of 3rd tool: continuity of patient care observational
experience in hospital, educational level, years of checklist developed by (Abdelrahman, 2021), it aims
work in the department and attending training to assess continuity of patient care. It consists of (5
program about documentation. sub dimensions) and (26 sub dimension) as follows:
Second part: Quality of nursing documentation medication administration record (2 items), vital signs
questionnaire it was developed by (Abdelrahman, record (4 items), fluids balance chart (4 items),
2021); it aimed to assess quality of nursing laboratory investigations record (4 items), nursing
documentation by staff nurses. This tool consists of (9 notes record (12 items).
dimensions) and (72 sub dimensions) as follow: types The scoring system for observed continuity of
of nursing formats availability (12 items), the reasons patient care was checked against (4) points Likert
of unavailability of formats (3 items), types of scale as follow: done and recorded (4), done but not
nursing formats kept in patient's file after discharge recorded (3), not done but recorded (2) and not done
(11 items), keeping formats (2 items), standards of and not recorded (1).
nursing documentation (10 items), attendance of Administrative design
training courses related to nursing documentation (12 An official approval to carry out this study obtained
items), factors influence quality of nursing from the Dean of Faculty of Nursing – Assiut
documentation (9 items), importance of quality University, Director of Elkharga general hospital,
documentation (7 items), and importance of Nursing director, and Nurses in Elkhaga general
continuity of patient care from nurses view (6 items). hospital to collect data.
it modified by the researchers one dimension was
deleted which is (responsibility of reviewing recorded Ethical considerations:
format), three dimensions have been added they were The ethics committee of the Assiut University Faculty
(standards of nursing documentation), (types of of Nursing has authorized a research proposal.
nursing formats availability) and, (factors influence Participants in the study are not at danger when the
quality of nursing documentation). research is applied. It is optional to take part in this
The scoring system: consists of three points were study. oral consent obtained from the study's subjects.
used to assess types of nursing formats availability as Each participant is free to leave the research at any
follow: available and use (2), available but not used time, for any reason. Assured anonymity and
(1) and unavailable (0). Two points were used to confidentiality. Privacy of study participants was
assess another dimension as follow (1) and (0) for taken into account while data was collected.
Yes and No respectively. Five points Likert scale Operational design:
used for answers to assess importance of The study was conducted throughout three main
documentation quality and importance of continuity phases: 1st preparatory phase,2nd pilot study, 3rddata
collection.

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Assiut Scientific Nursing Journal Ahmed et al.,

1st Preparatory phase: place over the course of around 4 weeks (one week
After reviewing the pertinent literature on the subject for each shift). The information was evaluated from
of how well documentation affects patient care work records kept by the nursing staff on the ward.
continuity, the study materials were translated into Three nurses, one from each unit, were taught by the
Arabic. Additionally, the study instruments' face researcher to assist them throughout the night shift by
validity was evaluated for "quality of nursing explaining the study's goals, relevance, methods, and
documentation." Five specialists (3 professors and 2 timetable for observations.
Assistant professor) from the Nursing Administration Each observer began their observations with the
Department of the Faculty of Nursing at Assuit people they had already met. The observer made an
University assessed questionnaires, a concurrent effort to repeatedly view several employees in the
auditing checklist on the quality of nursing same time assist her in watching the nurses. During
documentation and continuity of patient care, and the morning shift (7:30 am to 1:30 pm), afternoon
prepared observational checklists. shift (1:30 pm to 7:30 pm), and night shift (7:30 pm
2nd Phase pilot study On eight nurses, who represent to 7:30 am), the observers gathered data by
10% of the study's total participants and work at continuously watching the recording of nursing
Elkharga General Hospital, all the study tools were actions on each unit for 6 hours.
tested for internal reliability using Cronbach's alpha,
scoring a "0.80" result, to ensure that they were clear, Statistical design
easily accessible, and easy to understand. They were Data collected and analyzed using the computer
also timed before the data were actually collected. program SPSS" ver. 24" Chicago. USA. Data express
The data from the pilot research was examined, and as mean, Standard deviation and number, percentage.
any required adjustments were made. Mann-Whitney used to determine significant for
3rd Data collection phase numeric variable. Chi. Square used to determine
Real duration of data collection took place over a significance for categorical variable. Person's
three-month period, from January to March 2021. The correlation used for correlations between groups.
researcher visited each nurse to explain the purpose of Non-significant “n.s” P > 0.05 no significant, * P <
the study, confirm their consent, and let them know 0.05 significant, ** P<0.001 moderate significance,
that they might withdraw from the study at any and ** p<0.000 highly significance.
moment. All nurses' data were gathered utilizing the
research instruments. Each unit's data collection took

Results:

Table (1): Socio demographic data of the studied nurses group “n=80”.
Item No. %
1-Gender:
- Male 11 13.8
- Female 69 86.2
2-Job:
- Staff nurse 70 87.5
- Head nurse 10 12.5
3-Residence:
- Rural 28 35.0
- Urban 52 65.0
4-Educational level:
- Technical nursing associate diploma 17 21.2
- Secondary School of Nursing diploma +specialization 3 3.8
- Technical nursing diploma 60 75.0
5-Years of experience:
- <1year 4 5.0
- 1-<5 year 8 10.0
- 5-<10year 26 32.5
- ≥10years. 42 52.5

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Table (2): Distribution for quality of nursing documentation related to shift report per three shifts
“n= 120”
Recorded Not recorded
Contents of shift report Morning Afternoon Night Morning Afternoon Night
No. % No. % No. % No. % No. % No. %
- Patients description 120 100 120 100 120 100 0 0 0 0 0 0
- Patients new treatment 23 19.16 20 16.67 14 11.67 97 80.83 100 83.33 106 88.33
- Patients new medications 120 100 120 100 120 100 0 0 0 0 0 0
- New lab investigation 0 0 0 0 0 0 120 100 120 100 120 100
- Patients referral 54 45.0 26 21.67 30 25.0 66 55.0 94 78.33 90 75.0
- Patients complaints 0 0 0 0 0 0 120 100 120 100 120 100
- Emergency situations 56 46.67 42 35.0 24 20.0 64 53.33 78 65 96 80.0

100

50

Fig (1): Observed nursing documentation formats availability in patients record per three shifts “n= 120”

Table (3): Distribution for observed criteria for quality of nursing documentation “n= 120”
Yes No
General criteria for quality of nursing documentation
No. % No. %
Documents date 76 63.3 44 36.7
Complete entry of each shift 120 100 0 0
All entries are timed logically 0 0 120 100
Not identified erasures 51 42.5 69 57.5
Correct use of abbreviation 0 0 120 100
Avoiding duplication of information in the health record 112 93.3 8 6. 7
Nurses sign in full name for each entry 52 43. 3 68 56. 7
Errors have a single line marked 47 39.2 73 60.8
Correct spelling 67 55.8 53 44.2
Patient full name 120 100 0 0
Hospital number 101 84.2 19 15.8
No lines or spaces 51 42.5 69 57.5
Nurses actions are not recorded before they have been performed 46 38.3 74 61. 7
Use with confidentiality 0 0 120 100
Recording using clients own words 0 0 120 100
The information is accurate, factual & complete 0 0 120 100
Using different forms appropriately & completely 0 0 120 100

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Assiut Scientific Nursing Journal Ahmed et al.,

Table (4): Distribution of the Factors influencing quality of nursing documentation by study subject
(No=80)
Yes No.
Factor influence quality of nursing documentation
No. % No. %
- Nurses perform non nursing tasks 70 87.5 10 12.5
- documentation forms used by nurses 12 15.0 68 85.0
- The lack nurses’ knowledge about nursing documentation 7 8.7 73 91.3
- Documentation takes long time 80 100 0 0
- Shortage of nursing staff 80 100 0 0
- Un availability of nursing records &reports 3 3.8 77 96.2
- Nursing is not convinced of the Importance of nursing documentation 2 2.5 78 97.5
- Not enough time 80 100 0 0
- The environment surrounding nursing has a negative impact on the 80 100 0 0
quality of nursing documentation

Table (5): Distribution of the nurses opinions about the importance of quality of documentation
(no=80).
Yes No
Importance of quality of documentation
No. % No
- Conduction education & research 72 90.0 0 10.0
- Protection of the nurse’s rights 80 100 8 0
- Problem solving & decision making 18 22.5 62 77.5
- Keep the continuity of patient care 73 91.3 7 8.7
- Facilitates controls and supervision 7 8.8 73 91.3
- Away of communication among the health team members 80 100 0 0
- Protection in the patients and the hospital rights 80 100 0 0

Fig (2): Distribution of the Importance of continuity of patient care items of nursing documentation
(N=80).

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Assiut Scientific Nursing Journal Ahmed et al.,

Fig (3): Relationship between educational level of nurses quality of nursing documentation and
continuity of patient care “n=80”

Table (6): Correlation between observed quality of nursing documentation and continuity of
patients care at Elkharga general hospitals
quality of nursing documentation
Items
R P.V
Continuity of care of patients r= 0.578 P<0.000***

Table (1): Clarifies that, according to their gender & nursing care plan, patient admission assessment sheet
job, the majority of studied nurses are females is not available.
(86.2%) and staff nurses (87.5%). Regarding their Table (3): Shows distribution for observed criteria
residence, about two thirds of studied nurses from for quality of nursing documentation related to shift
urban (65%). In relation to their qualification, the report per three shifts. All nurses applied complete
majority of studied nurses (70%) have a technical entry of each shift and full patients name. While all of
diploma in nursing. Concerning their experience and them don’t applied recorded; all entries are timed
educational level, about half of studied nurses have logically, correct use of abbreviation, use with
(52.5%) equal or more than 10 years. confidentiality, recording using clients own words,
Table (2): Shows the distribution for quality of the information is accurate, factual & complete and
nursing documentation related to shift report at the Using different forms appropriately & completely.
three shifts. There was a decrease in the percentage of Table (4): Clarifies factor influence quality of
item recorded in afternoon shift and night shift than nursing documentation: in study subject. There is
morning shift. All data (100%) regarding patients (100%) of nurses agree about documentation takes
new medication and patient description were recorded long time, shortage of nursing staff, not enough time
in all shifts. There were many contents of shift report and the environment surrounding nursing has a
did not recoded as (patients complaints, new lab negative impact on the quality of nursing
investigation) (100%) at the three shifts. documentation and there is (87.5%) of nurses agree
Fig (1): Shows observed nursing documentation about nurses perform non nursing tasks
formats availability in patients per three shifts. All Table (5): Shows the nurses opinions about the
nurses agree that vital signs, nursing notes, importance of quality of documentation that observed
medication, insulin formats are available (120).While by studied subject. All nurses agree that the
the majority of them report that laboratory importance of quality of documentation for protection
investigation, change position, discharge plan, of the nurse’s rights, away of communication among
the health team members and protection in the

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Assiut Scientific Nursing Journal Ahmed et al.,

patients and the hospital rights but majority (91.25%) compliance, psychiatric treatments, and patient and
of them agree about Keep the continuity of patient nurse satisfaction. (Molin & Gallo, 2020).
care and (90.0%) of nurses agree about The present study aimed to the explore effect of
documentation conduct education &research. quality of nursing documentation on continuity of
Fig (2): Shows the importance of continuity of patient patient care.
care items of nursing documentation in study subject. Regarding to personal characteristics:
All nurses agree about the increase of patient The current survey showed that the majority of the
satisfaction, improve the quality of care and nurses were between the ages of 20 and 30. This
supported by the quality of documentation. result was in line with the findings of (Akhu Zaheya,
Fig (3): Declares the relationship between et al., 2018), who indicated that the majority of
educational level of nurses and quality of nursing nurses in the research sample were between the ages
documentation and continuity of patient care. There is of 20 and 30.
a significant difference (P<0.01) between level of Regarding to the quality of nursing documentation
education with total observed quality of nursing related to shift report per three shifts:
documentation mean score. In addition, there is The results of the current study showed that the
highly significant difference (P<0.000) with the total proportion of items recorded in the afternoon and
observed continuity of patient care mean score. Also, night shifts is lower than in the morning shifts. With
this table illustrates that nurse having technical the exception of the patients' new medicine and their
nursing diploma have the highest mean score description, which were documented (100%)
regarding the quality nursing documentation and throughout each shift. According to the researcher,
continuity of patient care. this outcome might be explained by the fact that there
Table (6): Shows correlation between observed weren't enough nurses working the afternoon and
quality of nursing documentation and continuity of night shifts.
patients care at Elkharga general Hospitals. There is a This results is in line with that reported by
positive significant correlation between score of (Abdelrahman et al. 2021)., who found that the
observed quality nursing documentation and score of proportion of time spent on documentation was
total continuity of patients care. independently related to day versus night shifts
(19.2% vs. 12.4%). Information retrieval is also
Discussion affected by the time of day.
Nursing documentation is essential in healthcare Regarding to observed nursing documentation
settings and reflects a number of factors, including formats availability in patients
the nurses' degree of understanding of their duties in The results of this study showed that all nurses concur
providing high-quality healthcare services (Osama, et that there were formats for vital signs, nursing notes,
al., 2016). and medication formats accessible. While the bulk of
The nursing documentation is seen to be a them claim that there was no laboratory investigation
requirement for effective communication, teamwork, sheet.
and high-quality patient care. It should include nurse These results corroborated those of (AbdElrahman
observations, evaluations, and choices (Chand & et al. 2021), who mentioned that there were available
Sarin, 2019). formats for vital signs, nursing notes, and medicines.
Among the shortcomings in nursing documentation Regarding observed criteria for quality of nursing
are time-consuming recording, poor patient portrayal, documentation
and incomplete records. The continuity and quality of The results of this study showed that every nurse
the care provided are impacted by ineffective entered every shift's entire patient name and data
information sharing and transfer, therefore hospital completely. While not all of them apply, all entries
administration, nurses, and nursing researchers have were rationally timed, correctly abbreviated, used
all expressed a desire to improve nursing with confidentially, recorded in the customers' own
documentation. Changes in record keeping practices words, and used with the proper and thorough use of
are frequently made to comply with legal obligations, various forms.
reduce paperwork, and uphold professional standards. These results are in line with those of (Abdelrahman
(Aldosari et al., 2018). et al., 2021) who reported that all entries are timed
The majority of the literatures often ignore the logically, that abbreviations are used correctly, that
behaviors and communication techniques that are confidentiality is maintained, that clients' own words
involved in the nurse-patient interaction and the roles are used when recording information, that the
that each plays in it. There is a ton of information information is accurate, factual, and complete, and
available on self-care techniques, medication that various forms are used appropriately and
completely.

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Assiut Scientific Nursing Journal Ahmed et al.,

Regarding to the factors influence quality of Regarding to correlation between quality of

nursing documentation by studied nurses: nursing documentation and continuity of patient
All of the nurses who participated in the current study care among study group:
were overworked and lacked time to complete patient The findings of the current investigation revealed a
paperwork. This outcome might be the result of very statistically significant positive link between the
improper task assignment and insufficient nurse standard of nurse documentation and patient
control, according to the study. continuity.
This result was in line with (Tasew et al.'s 2019) These results were in line with research by
findings that inadequate documentation forms, a lack (Abdelrahman et al., 2021), who found that good
of time, and knowledge with operational standards of nursing documentation improves clinical nursing,
nursing documentation all had a substantial impact on nursing education, and patient care while also
the practice of recording nursing care. This was also promoting nursing as a profession and increasing
in line with (Chand & Sarin's 2019) assessment, patient satisfaction with nurses. As a result, it shown
which said that inadequate records, erroneous patient that there is a very statistically significant positive
portrayal, and the labor-intensive nature of recording association between the standard of nursing
are only a few examples of the shortcomings in documentation and patient care continuity.
nursing documentation. These findings were also validated by additional
Regarding to the importance of quality of research by Marie & Jaroslav (2016) and which
documentation. demonstrated a highly statistically significant positive
The results of the current study showed that all nurses correlation between the standard of nursing
agreed on the need for nurse rights to be protected in documentation and the continuity of patient care.
documentation, on the need for health team members Moreover, the study's findings concur with those of
to communicate openly, and on the preservation of (Petersen, et al., 2017), who indicated that continuity
patient and hospital rights. The majority of nurses of patient care and the quality of nurse documentation
concurred that it is important to maintain continuity in had a highly statistically significant positive link.
patient care, document it, and carry out research and Additionally, a research by( Maarsingh et al., 2016)
education. found that a strong statistically significant positive
The research by (Molin & Gallo 2020), which shown link between the caliber of nursing documentation
that the majority of tested samples produced nursing and the continuity of patient care was consistent with
documentation of a generally recognized standard of the findings of the current study.
quality, is in keeping with these findings. The Regarding to nurses educational level, quality of
effectiveness of nursing documentation is seen to play nursing documentation and continuity of patient
a significant role in promoting organized, regular, and care:
efficient communication between caregivers, The results of the current study showed a significant
facilitating continuity and individuality of care, and relationship between mean scores for overall
enhancing patient safety. observed quality of nursing documentation and
Regarding to Importance of continuity of patient educational attainment. Additionally, the mean score
care items of nursing documentation for the whole observed continuity of patient care
According to the results of the current study, all showed a highly significant difference. Additionally
nurses believed that better service and better shows that nurses with technical nursing degrees have
documentation would boost patient satisfaction. From the average score for the consistency of patient care
the perspective of the researcher, this outcome may and the quality of nursing documentation.
be due to the fact that an observation checklist rather These results were in line with those of (Molina &
than a questionnaire was used to gauge the degree of Gallo 2020), who reported this result is that
continuity of patient care that was directly related to registered nurse had predominantly positive attitude
patient care and as the majority of the studied patients towards adequate knowledge of and acceptable
were exposed to this care through observation of practice behavior relating to record keeping. In
nurses' activities. addition, this result agreed to study by (Petresen, et
The findings of Marie & Jaroslav (2016) study were al., 2017) who found that qualified or senior nurse
in line with the findings of the current study in that supervising can contribute to record keeping.
good nursing documentation improves patient care Regarding to relationship between nurses
quality and patient satisfaction with nurses, helps educational level continuity of patient care and
advance nursing as a profession, and advances total observed quality of nursing documentation
clinical nursing and nursing education. Technical nurses had the highest mean scores in
relation to the total observed continuity of patient care
and the total observed quality of nursing

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Assiut Scientific Nursing Journal Ahmed et al.,

documentation in the current study, which found a  Holding workshop with the nursing staff about
statistically significant relationship between importance of nursing documentation.
educational level, continuity of patient care, and  Apply nursing documentation policies to guide
nursing documentation quality. This finding may be nurse’s performance.
explained by the fact that the majority of staff nurses  Continuous supervision of nursing documentation
have technical nursing backgrounds and have studied through regular and periodic auditing is suggested,
this subject at their institutions. with constructive feedback, as well as disciplinary
The findings of this study did not agree with those of actions for defaulters and rewards for good
a study by (AkhuZaheya et al. 2018) that looked at achievers.
the effect of nurse staffing and education on patient  The hospital administration should address the
fatalities in hospitals with different nurse work barriers to adequate nursing documentation
conditions. They discovered that the quality of identified by the nurses, and provide all needed
treatment and patient outcomes are both improved resources.
when there are more nurses with bachelor degrees.  Provide opportunities to attend national and
Additionally, the results of this study were at odds international nursing conferences to improve their
with those of the American Association of Colleges knowledge about nursing documentation.
of Nursing, which claimed that schooling had a  Reinforce the application of the following sheets;
significant impact on nurse practitioners' knowledge laboratory investigation, discharge plan, nursing
and competencies, just as it did for all other care plan, patient admission assessment.
healthcare professions. Additionally, the results of  Nurse managers must ensure that nursing personnel
this investigation concurred with those of (Chand & apply all nursing documentation properly
Sarin 2019).
References:
Conclusion  Abd ElRahman A., Ibrahim M. & Diab G.,
 All hospital nurses concurred on the significance of (2021): The effectiveness and efficiency of nursing
nursing documentation quality and patient care care documentation nursing the SIMPRO model.
continuity; the majority of examined samples Menoufia Nursing journal vol.6.No
produced acceptable levels of nursing  Abd El Rahman A., Ibrahim M. & Diab G.,
documentation quality, and the majority of all (2021): Quality of Nursing Documentation and its
analyzed samples produced average levels of patient Effect on Continuity of patients’ care. MNJ, Vol. 6,
care continuity. No. 2, Nov, PP: 1-18.
 The majority of the nurses had an average degree of  AkhuZaheya, L., Al Maaitah, R., & Bany Hani,
continuity of patient care, and there was an accepted S. (2018): Quality of nursing documentation: Paper
level of nursing documentation quality. based health records versus electronic based health
 The mean scores for the quality of nursing records. Journal of clinical nursing, 27(3-4), e578-
documentation and continuity of patient care were e589.
highest among nurses with nursing technical  Aldosari B, Al-Mansour S, Aldosari H., &
dipoma degrees. The continuity of patient care and Alanazi A. (2018): Assessment of factors
the quality of nursing documentation showed a influencing nurses‟ acceptance of electronic
highly statistically significant positive correlation. medical record in a Saudi Arabia hospital.
 The majority of nursing documentation criteria, Informatics in Medicine Unlocked.2018;10:82-88
including utilizing different forms appropriately,  Alqattan H, Cleland J, & Morrison Z (2018): An
correct use of abbreviations, confidentiality, and evaluation of patient safety culture in a secondary
entries that are timed rationally, were all agreed care setting in Kuwait. J TaibahUnivMed Sci.;
upon by the nurses. 13(3):272–280.
 All nurses agreed that almost of the nursing  Chand S. & Sarin J. (2019): Confident or
documentation criteria did not applied such as all Confused: Nurses’ Perception and Acceptability of
entries are timed logically, correct use of Electronic Nursing Documentation, International
abbreviations, use confidentiality, recording using Journal of Health Sciences & Research 197 Vol.9;
clients own words and using different forms Issue: 10;
appropriately.  Gautun, H., & Syse, A. (2017): Earlier Hospital
Discharge: a challenge for Norwegian
Recommendations Municipalities. Nord J. Soc. Res. 8, 1–17.
Based on the findings of the present study, the doi:10.7577/njsr.2204
following recommendations were suggested:  Herisiyanto A., Sulistyadi K., Ramli S., &
Abdullah S., (2020): The Effect of Nursing

Vol , (11 ) No, ( 93 ), September, 2029, Pp (17 - 27 ) 26

Assiut Scientific Nursing Journal Ahmed et al.,

Documentation and Communication Practices on

Patient Safety Practices in the Pemalang Ashari
Hospital. Asian Journal of Research in Nursing and
Health 3(1): 10-19, Article no.AJRNH.55278.
 Maarsingh, O., Henry, Y., VandeVen, P., &Deeg,
D. (2016): Continuity of care in primary care and
association with survival in older people: a17-year
prospective cohort study. British Journal of General
Practice, 66(649), e531-e539.
 Marie, T., & Jaroslav, P. (2016): Provision of
Nursing Care withor without Therapeutic
Communication Intervention.US-China L. Rev., 13,
75.
 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. 27(3):491–501.
doi: 10.1111/jonm.12727.
 Moldskred P., Snibsøer A., & Espehaug B.,
(2019): Improving the quality of nursing
documentation at a residential care home :a clinical
audit, BMC Nursing
https://doi.org/10.1186/s12912-021-00629-9
 Molina J., & Gallo J., (2020): Impact of nurse-
patient relationship on quality of care and patient
autonomy in decision-making. International journal
of environmental research and public health, 17(3),
835.
 Osama A., AlkouriAhed J., & Kawafhah. A,
(2016): Importance and Implementation of Nursing
Documentation: Review Study European Scientific
Journal January edition vol.12, No.3 ISSN: 1857 –
7881.
 Petersen, J., Rasmussen, L., & Rydahl S., (2017):
Barriers and facilitating factors related to use of
early warning
score among acute care nurses: A qualitative study.
BMC emergency medicine, 17(1), 1-9.
 Tasew H., Mariye T., & Teklay G., (2019):
Nursing documentation practice and associated
factors among nurses in public hospitals, Tigray,
Ethiopia. BMC Res Notes. 12:612.
 Wang F., (2018): The impact of mobile technology
on teamwork and communication in hospitals: A
systematic review. Journal of the American Medical
Informatics Association.;26.

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