Documentation compliance of in-patient files: A cross sectional study from an east India state

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Clinical Epidemiology and Global Health


Aim: To assess the knowledge, attitude and practices of nurses regarding in-patient file documentation. Background: Documentation is a communication tool that helps in the exchange of information stored between caregivers. Quality documentation promotes structured, consistent and effective communication between healthcare providers. This is a preliminary study on the documentation in tertiary care hospitals for initial steps to be taken by the concerned health officers and decision makers. Methods: A descriptive cross-sectional study was carried out with a total of 80 respondents who were selected conveniently from a tertiary care hospital in Durgapur. Study utilized a dichotomous self-administered questionnaire. Qualitative characteristics were summarized using frequency and percentages. Chi-square test was used to investigate associations. Statistical Package for Social Sciences (SPSS, Version 25, Licensed by IIHMR University, Jaipur) was used for analysis. Results: Majority of the nurse (67.5%, n = 54) had satisfactory knowledge, attitude & practice. Chi-squared test of association revealed no significant relation between gender and knowledge, attitude & practice (χ2 = 0.15, df = 1 and p = 0.697). No significant association of knowledge, attitude & practice was observed with age (χ2 = 1.48, df = 2 and p = 0.477) and years of experience (χ2 = 2.31, df = 1 and p = 0.128). Conclusion: The nurses appeared to be familiar with the required documentation knowledge. A pressing need was felt to emphasize on all aspects of in-patient documentation under continuous nursing education program. Newly appointed nurses were equally good in documentation compared to their senior counterparts. This study advocates the necessary actions to be taken for enabling nurses for timely documentation of patient details for improved communication with other health workers.

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