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Nurses’ perspectives of the nursing documentation audit process

M. Mokholelana Ramukumba
Souher El Amouri


Background: Nursing has an obligation to the public to develop measures for the quality of care to enhance patient safety and efficiency of the  system. The first hospital to introduce the clinical audit of nursing documentation was in Abu Dhabi. The rationale was the recognition of the link between clinical audits and the quality of patient care and safety. This article recognises the importance of documentation audits in nursing practice  and the role of nurses related to conducting audits in a selected hospital in Abu Dhabi. Many studies have shown the potential benefits of documentation audits to evaluate or assess the quality of recorded nursing assessments and care.

Aim: The aim of this study was to explore nurses’ perspectives of the documentation audit process.

Method: The study adopted an exploratory, descriptive qualitative approach using the evaluation method. Data were collected using three focus group interviews consisting of 4 informatics and 13 documentation link nurses involved in the implementation of the clinical audit on nursing documentation in the selected hospital. Thematic analysis was used to analyse the data.

Results: Three major themes evolved from the research findings: implementation of documentation audit, evaluation of audit and measures to  improve documentation audit. Strengths and weaknesses of the documentation audit were articulated by the nurses. Generally, nurses were satisfied with the audit process and made recommendations on improvements.

Conclusion: Processes adopted by the team were reasonable and useful, and the preparation and planning for the clinical audit were regarded as areas of strength. Areas of weaknesses in the implementation processes identified included dissemination of findings and executing improvements. This could be improved with necessary support from the hospital management, especially with regard to release time to implement required  changes. The complexity of auditing electronic versus paper-based nursing documentation is acknowledged.

Keywords: assessment; audit process; evaluation; nursing documentation; quality initiative.