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Learning Objective 1: The purpose of nursing documentation is communicating and sharing information on the patient's status throughout the hospitalization with health care team members
Learning Objective 2: Patient records may be studied by researchers to learn how best to recognize or treat health problems. Registered nurses knowledge of nursing documentation is important.
This study addressed the registered nurses' knowledge of documentation in two geriatric wards in Khoo Teck Puat Hospital The purpose of nursing documentation is communicating and sharing information on the patient's status throughout the hospitalization with health care team members. A legal document and admissible in court as evidence. It assists in patient care planning; each professional working with the patient has access to the patient's baseline and ongoing data. Patient responds to the treatment plan from day-to-day is documented. Modifications of the plan of care are then based on this data. It acts as a form of audit; patient records may be reviewed to evaluate the quality of care received and to improve the quality of care. Patient records may be studied by researchers to learn how best to recognize or treat health problems. Registered nurses knowledge of nursing documentation is important.
Methods:
A Cross-sectional, retrospective design was used The study was conducted with 40 RNs (n=40) in two geriatric wards. Participants completed a questionnaire where they identified factors that influence their knowledge and understanding of documentation
Results:
Participants stipulated that they have considerable knowledge of nursing documentation. They said that they were most knowledgeable about documentation policies and writing instructions on discharge. Their knowledge of nursing assessments ranked fifth and they were least knowledgeable about reading their reports every shift
Conclusion:
A modified Edelstein's questionnaire was a valid and reliable instrument measuring RNs' knowledge of nursing documentation. A factor analysis of the 13 items in the Knowledge scale showed excellent reliability. The data indicated that RNs in the two geriatric wards have high levels of knowledge about documentation
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