Record-keeping: Challenges experienced by nurses in selected public hospitals

Abstract

Background: Patients’ records provide a trace of care processes that have occurred and are further used as communication amongst nurses for continued management of patients. Nurses have the responsibility to ensure that records are accurate and complete in order to effectively manage their patients. In hospitals, nurses have to record a wide range of information in the patient’s records and this leads to increased workload on the part of nurses that compromises accurate record-keeping.

Objectives: The purpose of this study was to explore and describe the challenges experienced by nurses with regard to record-keeping at selected public hospitals in the Vhembe district, Limpopo Province, South Africa.

Method: A qualitative, explorative and descriptive research design was used. Nurses working in selected public hospitals were purposively selected and semi-structured interviews were conducted until data saturation was reached. Data were analysed using the Tesch’s open-coding method.

Results: Nurses working in public hospitals experience record-keeping as a challenging activity owing to a variety of challenges which include lack of time to complete the records, increased patients’ admission and shortage of recording material.

Conclusion: Record-keeping is not done properly which is problematic, and it is recommended that there should be continuous training, monitoring and evaluation of nurses on record-keeping issues, supply of adequate recording materials and proper time management amongst nurses to improve record-keeping challenges. The need for comprehensive record-keeping remains fundamental in public hospitals in order to improve patient care.