ABSTRACT
Documentation is vital for a safe, ethical, and effective nursing care in clinical setting. Nursing practice requires documentation to ensure continuity of care, planning, and accountability, as well as in the promotion and uptake of evidence-based practice. The aim of the study was to assess the attitude and practice of nursing documentation among nurses in selected primary health centers. The study used a quantitative, descriptive survey design in which self-administered questionnaires were distributed to a sample size of 120 staff nurses. With the aid of SPSS version 20, data were analyzed using a descriptive statistics. Majority of the participants were females 92(76.7%) and most of the respondents’ years of experience are within the range of 1-10years (63.3%). Findings showed that nurses had good knowledge on nursing documentation with majority 106(88.4 %)of the nurses having a good knowledge, 11(9.2%) nurses had fair knowledge and 3(2.5%) had poor knowledge. One hundred and sixteen 116(96.7%) nurses had positive attitude towards documentation while 4(3.3%) nurses had negative attitude toward documentation showing that nurses had positive attitudes towards documentation. Lastly, the level of practice of documentation by the nurses showed that 117(97.5) nurses had high practice while 3(2.5%) nurses had low practice, indicating a high practice of documentation among the nurses. Proper and effective nursing documentation is very important in hospitals and effective ways of improving nurse’s attitude and practice on documentation more, should be conducted through seminars and workshops.It was recommended that more enlightenment programs in form of public seminars should be organized so as to continue to improve nurses awareness on nursing documentation and educate them more of the importance of documenting patient’s care.
