Nursing documentation is an important tool for
evaluating the care provided by the caregivers and
It emphasizes on monitoring quality of health-care
based on the patients’ outcomes .
Nursing documents can be used for:
(i) Ensuring quality of care through communication
(ii) Furnishing legal evidence of the process and outcomes of care
(iii) Evaluation of the quality, efficiency and effectiveness of the
(iv) Providing data for research, financial and ethical quality assurance
(v) Providing the infrastructure supporting development of nursing
(vi) Assisting in establishing benchmarks for the development of
nursing education and standards of clinical practice ;
(vii) Ensuring the appropriate reimbursement;
(viii) Providing the data for future health-care planning ; and
(ix) Providing data for other purposes such as risk
management, learning experience for students, protection of
patients’ rights .
To identify the knowledge regarding nursing
To assess the practice regarding nursing
To find out association of knowledge and practice with
the selected variables.
To find out the relationship between the knowledge
Knowledge of nurses regarding nursing documentation
Practice of nurses regarding nursing documentation
Related training and/or workshop
Frequency of supervision
Age: completed years at last birthday
Work experiences: completed years and months
Related CNE, training and workshop
If yes, specify…………………
Nursing audit on documentation
Knowledge : Nurses' knowledge will evaluate by
prepared questionnaires on nursing domains related to
accuracy of record keeping and
significance of documentations.
Checklists will provide covering four areas:
Vital sign and
I & O of fluids.
selected hospitals of eastern region
Selected nurses from selected hospitals
Stratified population proportionate systematic random
First: form strata of hospitals: medical
college, zonal hospital, district hospital and private
hospitals above 50 beded and randomly select from 1
medical college, 1 zonal hospital, 4 district hospital
and 4 private hospitals from each strata
Second: population proportionate each hospital
Third: Simple random sampling
Formal approval will be obtained from the concerned
Informed written consent will be obtained from each
respondent before giving the questionnaire.
Confidentiality and anonymity will be maintained
throughout the study and will be maintained later.
Jasemi M, Zamanzadeh V, Rahmani A, Mohajjel A,
Alsadathoseini F. (2012). Knowledge and Practice of
Tabriz Teaching Hospitals’ Nurses Regarding Nursing
Documentation. Thrita Journal of Medical
Wang N, Hailey D, Yu P. (2011). Quality of nursing
documentation and approaches to its evaluation: a
mixed-method systematic review. Journal of Advanced
Nursing 00(0), 000–000. doi: 10.1111/j.13652648.2011.05634.x
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