Determinants of Incomplete Documentation of Nursing Care: A Cross-Sectional Study

Background: Incomplete documentation of nursing care may be related to individual characteristics, including age, length of work, education, and supervision.Aim: The current research was conducted with aim to determine the determinants of incomplete documentation of nursing care on the ward.Method: This analytic observational research was conducted using a cross-sectional design involving ۱۰۵ ward nurses. Data was collected using a checklist form including translated MCSS-۲۶ and a researcher-made nursing documentation checklist. Data analysis was performed by SPSS software (version ۱۶) and chi-square test. p<۰.۰۵ was considered statistically significant.Results: There was a relationship between nursing documentation and gender (p<۰.۰۰۲), education level (p<۰.۰۱۷), and good supervision (p<۰.۰۰۳). The correlation test using the t-test showed that there was no relationship between age and nursing care documentation (p>۰.۶۸۸), nor between work length and nursing care documentation (p>۰.۵۱۶).Implications for Practice: This study has identified the weaknesses of the nurse documentation system in the nursing wards. This has implications for increasing nurse and patient satisfaction and can also increase hospital accreditation and improve the quality of nursing care services.

کلیدواژه ها:

Characteristics ، documentation ، Nursing ، supervision