DOCUMENTATION PRACTICES AND ASSOCIATED FACTORS AS PERCEIVED BY STAFF NURSES

Abstract

Background: Nursing documentation is essential for patient safety, continuity of care, communication, and legal accountability. However, inadequate knowledge and patient-related challenges may affect documentation practices. Objective: To assess nurses’ knowledge and perceptions of nursing documentation and identify associated patient-related and organizational factors. Methodology: A cross-sectional correlational study was conducted among 150 staff nurses in two tertiary care hospitals in Lahore. Data were collected through a structured questionnaire and analyzed using descriptive statistics, Spearman’s correlation, and non-parametric tests. Results: The mean knowledge score was 4.78 ± 1.81/9, with 70% of nurses having poor knowledge. Perceptions toward documentation were strongly favorable (mean = 1.54 ± 0.39). Patient-related factors were significantly associated with documentation practices (r = 0.333, p < 0.001), while organizational factors were not significant (r = 0.142, p = 0.082). Knowledge also differed significantly by gender and work unit. Conclusion: Nurses had favorable perceptions but inadequate knowledge of nursing documentation, particularly regarding legal and professional accountability. Regular documentation training and continuing professional development are recommended.