Quality of nursing documentation at bugando medical centre in tanzania: A retrospective patients’ medical records audit

Poor quality of nursing documentation has been an agenda, not only at Bugando Medical Centre (BMC) but also at national level in Tanzania. In trying to fix the problem, this study was conducted to ascertain the quantity and quality of nursing documentation by auditing the patients’ medical records.

A descriptive cross sectional study design was used to audit the quantity and quality of nursing documentation from the medical records of inpatients admitted via emergency medical department (EMD) route and discharged within the three months prior the first day of data collection. A Statistical Package for Social Sciences (SPSS) 21^st version computer software was used for data analysis gathered by the use of the Norwegian Catch audit instrument (N-Catch). The study started upon approval from the CUHAS/BMC Research and Ethical Committee (CREC), and permitted for data collection from the Director General BMC.

This study involved patients’ medical records (n= 387) sampled from the four BMC departments such as Obstetrics and Gynecology, Internal Medicine, Paediatric, and Surgery. The patients whose medical records reviewed had 3 median days of hospital stay with 6 interquartile range. This study found that nurses document incomplete information pertained to the care provided in the patients’ medical records. Likewise, majority of the information documented are below the minimum standard of good quality. Further study that aims at understanding factors influencing nursing documentation at BMC are warranted.