The Relationship between Nursing Knowledge about Documentation Skills and Auditing Retrospective of Patient's Records

Abstract

Documentation plays a vital role in the appropriate planning of nursing care services, the accurate recording of daily events, and the satisfaction and well-being of patients. Accurate, timely, thorough and concise documentation can be the deciding factor for whether a patient lives or dies. Aim: The study aimed to explore the relationship between nursing knowledge about documentation skills and auditing retrospective of patient's records. Design: Quasi experimental research design was used in this study. Setting: The study was conducted at Badr University Hospital. Subject: Consist of a convenience sample (80) of nursing personnel. Data collection: Two tools were used in this study as 1st tool: Self-administered Questionnaire sheet that consisted of two parts, part 1: Personal Characteristics Sheet, part 2: Part 2: Self administrated sheet for nurses' knowledge about documentation skills.2nd tool: Auditing retrospective sheet of patient's records. Results: The majority of them had a moderate level of nursing personnels' knowledge regarding total documentation dimensions and gained higher percentage of excellent level of performance for them. Conclusion: There was a highly statistically significant positive correlation between knowledge and performance regarding documentation skills among nursing personnel. Recommendations: This study recommended Conduct in service training to increase nursing personnel awareness about documentation skills.