Original Research - Special Collection: Contemporary Issues in Nursing
Record-keeping: Challenges experienced by nurses in selected public hospitals
Submitted: 01 March 2018 | Published: 30 July 2018
About the author(s)
Takalani E. Mutshatshi, Department of Nursing Science, University of Limpopo, South AfricaTebogo M. Mothiba, Department of Nursing Science, University of Limpopo, South Africa
Pamela M. Mamogobo, Department of Nursing Science, University of Limpopo, South Africa
Masenyani O. Mbombi, Department of Nursing Science, University of Limpopo, South Africa
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.
Keywords
Metrics
Total abstract views: 12166Total article views: 10377
Crossref Citations
1. Nurses’ Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study
Fitalew Molla, Worku Animaw Temesgen, Sitotaw Kerie, Destaw Endeshaw
SAGE Open Nursing vol: 10 year: 2024
doi: 10.1177/23779608241227403
2. Strategies for enhancing training and development in healthcare management
Michael M. Willie
SA Journal of Human Resource Management vol: 22 year: 2024
doi: 10.4102/sajhrm.v22i0.2523
3. Micronutrient supplementation practices in relation to the World Health Organisation 2013 guidelines on management of severe acute malnutrition
Doris Cement Nanga, Janet A. Carboo, Humphrey Chatenga, Arista Nienaber, Cornelia Conradie, Martani Lombard, Robin Claire Dolman‐Macleod
Maternal & Child Nutrition vol: 20 issue: 3 year: 2024
doi: 10.1111/mcn.13636
4. Bridging the gap in electronic health records
Craig Mortimer
Journal of Paramedic Practice vol: 17 issue: 11 first page: 474 year: 2025
doi: 10.12968/jpar.2025.0065
5. Understanding the learning needs to enhance clinical competence of new professional nurses in public hospitals of South Africa: A qualitative study
Kholofelo L. Matlhaba, Naomi L. Nkoane
Belitung Nursing Journal vol: 8 issue: 5 first page: 414 year: 2022
doi: 10.33546/bnj.2180
6. A comparison of daytime and out of hour mental health presentations to Beaumont Hospital Emergency Department between 2018 and 2020
Yasoda Subramanian, Jack Barrett, San Kim, Cornelia Carey, Helen Barry, Siobhan MacHale
Irish Journal of Medical Science (1971 -) vol: 192 issue: 5 first page: 2475 year: 2023
doi: 10.1007/s11845-022-03249-7
7. Medical documentation practice and its association with knowledge, attitude, training, and availability of documentation guidelines in Ethiopia, 2022. A systematic review and meta-analysis
Sisay Yitayih Kassie, Addisalem Workie Demsash, Alex Ayenew Chereka, Yitayish Damtie
Informatics in Medicine Unlocked vol: 38 first page: 101237 year: 2023
doi: 10.1016/j.imu.2023.101237
8. Ethical and Legal Challenges in Caring for Older Adults with Multimorbidities: Best Practices for Nurses
Abdulaziz M. Alodhialah, Ashwaq A. Almutairi, Mohammed Almutairi
Healthcare vol: 12 issue: 16 first page: 1585 year: 2024
doi: 10.3390/healthcare12161585
9. Evaluation of the current status of prosthetic rehabilitation services for major limb loss: a descriptive study in Ugandan Referral hospitals
Benedict Mulindwa, Racheal P. Nalwoga, Brenda T. Nakandi, Erisa S. Mwaka, Laurence P. J. Kenney, Louise Ackers, Robert Tamale Ssekitoleko
Disability and Rehabilitation vol: 46 issue: 5 first page: 969 year: 2024
doi: 10.1080/09638288.2023.2188266
10. Electronic health records: implications for patient safety and continuity of care
Craig Mortimer
Journal of Paramedic Practice vol: 18 issue: 2 first page: 1 year: 2026
doi: 10.12968/jpar.2026.18.2.CPD1
11. Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite quasi‐experimental study
Belinda Munroe, Kate Curtis, Margaret Fry, Ramon Z. Shaban, Peter Moules, Tiana‐Lee Elphick, Kate Ruperto, Tracey Couttie, Julie Considine
Journal of Clinical Nursing vol: 31 issue: 19-20 first page: 2874 year: 2022
doi: 10.1111/jocn.16115
12. Post-trial perceptions of a symptom-based TB screening intervention in South Africa: implementation insights and future directions for TB preventive healthcare services
Nicole Salazar-Austin, Minja Milovanovic, Nora S. West, Molefi Tladi, Grace Link Barnes, Ebrahim Variava, Neil Martinson, Richard E. Chaisson, Deanna Kerrigan
BMC Nursing vol: 20 issue: 1 year: 2021
doi: 10.1186/s12912-021-00544-z
13. Risk to patients, risk to clinicians: a three-site audit of the documentation of counselling in first episode genital herpes
Ellen Cornish, Emily Clarke, Joshua Gahir, Joanna Rees, Raj Patel
International Journal of STD & AIDS vol: 31 issue: 12 first page: 1212 year: 2020
doi: 10.1177/0956462420955061
14. Experiences of operational managers regarding record keeping by new professional nurses in public hospitals in the North West province, South Africa
Naomi L. Nkoane
Health SA Gesondheid vol: 46 issue: 1 year: 2023
doi: 10.4102/hsag.v28i0.2257
15. Exploring quality standards implementation at a South African municipality’s health facilities
Rose S. Matahela, Ayobami P. Adekola, Azwihangwisi H. Mavhandu-Mudzusi
Curationis vol: 46 issue: 1 year: 2023
doi: 10.4102/curationis.v46i1.2416
16. Midwives’ experiences regarding recordkeeping during intrapartum care in Limpopo Province healthcare facilities
Phogole C. Maesela, Johanna M. Mathibe-Neke
Curationis vol: 47 issue: 1 year: 2024
doi: 10.4102/CURATIONIS.v47i1.2594
17. Exploring strategies to improve documentation of nursing notes in hospitals globally: An integrative review
Immaculate Sabelile Tenza, Priscah Mosol, Ntsoaki Tshabalala, Claudine Muraraneza, Pamella Adongo, Moses Mutua Mulu
International Journal of Africa Nursing Sciences vol: 24 first page: 101013 year: 2026
doi: 10.1016/j.ijans.2026.101013
18. Health System- and Patient-Related Factors Associated with COVID-19 Mortality among Hospitalized Patients in Limpopo Province of South Africa’s Public Hospitals
Musa E. Sono-Setati, Peter M. Mphekgwana, Linneth N. Mabila, Masenyani O. Mbombi, Livhuwani Muthelo, Sogo F. Matlala, Takalani G. Tshitangano, Naledzani J. Ramalivhana
Healthcare vol: 10 issue: 7 first page: 1338 year: 2022
doi: 10.3390/healthcare10071338
19. Challenges in data documentation and retrieval in the ASHA diary from a usability perspective
Sakshi Patel, Puneet Tandon
Social Science & Medicine vol: 382 first page: 118370 year: 2025
doi: 10.1016/j.socscimed.2025.118370
20. Qualitative exploration of manual dental records in the digital era using sociotechnical systems theory: insights from a teaching dental institution
Syuwari Azhar Azman, Sulhi Abidin, Galvin Sim Siang Lin, Mohd Haikal Muhamad Halil
Journal of Yeungnam Medical Science vol: 43 first page: 9 year: 2026
doi: 10.12701/jyms.2026.43.9
21. Quality of subjective, objective, assessment, and plan-based clinical documentation and its predictive value on treatment planning in excisional biopsy cases: A retrospective study
Namira K Fateen, Pratibha Ramani
Journal of Laboratory Physicians vol: 18 first page: 24 year: 2025
doi: 10.25259/JLP_231_2025
22. Identification of systemic barriers, facilitators and adaptations to effective record-keeping: a South African primary healthcare clinic case study
Kirsten Kingwill, Andrew Todd, Jonathan Davy
Ergonomics first page: 1 year: 2026
doi: 10.1080/00140139.2026.2696389
23. Workforce Challenges for the Neurosurgical Care of Brain Tumors in Low- and Middle-Income Countries: A Scoping Review
Muhammad Shakir, Aly Hamza Khowaja, Syeda Fatima Shariq, Hammad Atif Irshad, Izza Tahir, Ali I. Rae, Radzi Hamzah, Saksham Gupta, Kee B. Park, Syed Ather Enam
World Neurosurgery vol: 189 first page: 387 year: 2024
doi: 10.1016/j.wneu.2024.06.098
24. Acute care nurses' experience in providing evidence‐based care for patients with laparotomy wounds: A scoping review
Sarah Hulbert‐Lemmel, Auxillia Madhuvu, Victoria Team
International Wound Journal vol: 21 issue: 4 year: 2024
doi: 10.1111/iwj.14591
25. A closer observation of the dedicated responsibilities of nurses at public hospitals in Bangladesh
Shahinur Parvin, Murshida, M. Atiqur Rahman, Sharmin Akter Sumi, Stephen Kpekura, Zeshaan Yahaya Haji Mahmood, M. Ahasan Ali
International Journal of Scientific Reports vol: 10 issue: 8 first page: 262 year: 2024
doi: 10.18203/issn.2454-2156.IntJSciRep20241990
26. Documentation practices among ICU nurses: Contributory to patient’s safety
Jemmalyn D Piol
International Journal of Research Studies in Psychology vol: 9 issue: 1 year: 2023
doi: 10.5861/ijrsp.2023.2007
27. Vehicle extrication in road traffic crashes: a descriptive analysis of an advanced medical rescue service in South Africa
Naseef Abdullah, Jaydon Rose, Egnall Brown, Heike Geduld
African Journal of Emergency Medicine vol: 15 issue: 2 first page: 621 year: 2025
doi: 10.1016/j.afjem.2025.04.003
28. Nurses’ Practices During Implementation of the Nursing Process at a Selected Public Hospital of Limpopo Province, South Africa: A Qualitative Pilot Study Analysis
Takalani E. Mutshatshi, Tebogo M. Mothiba
The Open Public Health Journal vol: 13 issue: 1 first page: 309 year: 2020
doi: 10.2174/1874944502013010309
29. Perceived stress in end-of-life care: a qualitative study of Iranian nurses' experiences
Royani Zahra, Yazdi Khadijeh, Mahmoodi Shen Gholam Reza
International Journal of Palliative Nursing vol: 31 issue: 1 first page: 30 year: 2025
doi: 10.12968/ijpn.2025.31.1.30
30. Responsabilidades éticas en la práctica de enfermería en instituciones de alta complejidad
Dora Inés Parra, Senieth Deyanire Peñaloza Jaimes, María Vivina Cárdenas Villabona, Nelly Rey de Cruz, Helda Cecila Amaya Díaz, Ligia Betty Arboleda de Pérez, Yaneth Corredor Jurado
Revista Cuidarte vol: 10 issue: 3 year: 2019
doi: 10.15649/cuidarte.v10i3.662
31. Voices From the Frontline: A Qualitative Study of Nurses’ Experiences With Documentation and Its Influence on Patient Safety
Reem Saeed Alghamdi, Monirah Albloushi, Marwa Alshareef, Hind Alshamry, Alaa Alabdulaal, Nadyah Alshakarah, Maryam Alrashidi, Abdulqadir J. Nashwan
Journal of Nursing Management vol: 2026 issue: 1 year: 2026
doi: 10.1155/jonm/6217086
32. The nurses’ perception of the factors influencing professional misconduct: A qualitative study
Akram Ghobadi, Leila Sayadi, Nahid Dehghan Nayeri, Alireza Namazi Shabestari, Shokoh Varaei
Nursing Ethics vol: 31 issue: 2-3 first page: 281 year: 2024
doi: 10.1177/09697330231184469
33. PMTCT Data Management and Reporting during the Transition Phase of Implementing the Rationalised Registers in Amathole District, Eastern Cape Province, South Africa
Oyebanji G. Oyebola, Jackson Debra, Mathole Thubelihle
International Journal of Environmental Research and Public Health vol: 19 issue: 23 first page: 15855 year: 2022
doi: 10.3390/ijerph192315855
34. Family planning service availability and readiness assessment of primary health care facilities in Delta State, Nigeria: a mixed methods survey
Dorcas Tom Obong, Patrick Oyibo
Reproductive Health vol: 20 issue: 1 year: 2023
doi: 10.1186/s12978-023-01693-x
35. Evaluation of Exome Sequencing Criteria for Hospital Stewardship and Insurance Authorization at a Pediatric Hospital
Claire L. Wittowski, Sarah Clowes Candadai, Marie E. Perrone, Daniel F. Gallego, Jessie H. Conta, Jane A. Dickerson
Archives of Pathology & Laboratory Medicine vol: 146 issue: 1 first page: 107 year: 2022
doi: 10.5858/arpa.2020-0572-OA
36. Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021
Mulugeta Desalegn Kasaye, Miftah Abdella Beshir, Berhanu Fikadie Endehabtu, Binyam Tilahun, Habtamu Alganeh Guadie, Shekur Mohammed Awol, Mulugeta Hayelom Kalayou, Tesfahun Melese Yilma
BMC Health Services Research vol: 22 issue: 1 year: 2022
doi: 10.1186/s12913-022-07809-6
37. Identifying the Software Quality Attributes that Affect Patient Portal Adoption in Trinidad and Tobago
Marcus Rawlins, Xuejun Yu
SN Computer Science vol: 5 issue: 2 year: 2024
doi: 10.1007/s42979-023-02589-0
38. Perspectives on waiting times in an antenatal clinic: A case study in the Western Cape
Justine C. Baron, Doreen Kaura
Health SA Gesondheid vol: 26 year: 2021
doi: 10.4102/hsag.v26i0.1513
39. Reflections on an engaged research approach to understanding patient record-keeping systems in a local clinic in Makhanda
Kirsten Kingwill, Andrew Todd, Jonathan Davy, Siphosethu Pama
African Journal of Higher Education Community Engagement vol: 1 issue: 2 first page: 1 year: 2024
doi: 10.21504/ajhece.v1i2.2497
40. Challenges for Improving Nursing Documentation at PHCs, Riyadh, Saudi Arabia
Tariq Al Hajla, Lapurisima Domingo, Sultan Al Otaibi, Sultan Al Mutairi, Jennie Lou Buelva, Ali Al Rashedi, Meshael Al Otaibi, Azzam Alotaibi, Medhat Maher, Mostafa Kofi
European Journal of Medical and Health Research vol: 2 issue: 5 first page: 303 year: 2024
doi: 10.59324/ejmhr.2024.2(5).33
41. Exploration of note writing by mental health nurses using a video scenario
Krystle Martin, Korri Bickle, Rosemary Ricciardelli, Jessica Lok
Journal of Clinical Nursing vol: 32 issue: 11-12 first page: 2672 year: 2023
doi: 10.1111/jocn.16342
42. Improvements in Obstetric and Newborn Health Information Documentation following the Implementation of the Safer Births Bundle of Care at 30 Facilities in Tanzania
Benjamin Anathory Kamala, Hege Ersdal, Robert Moshiro, Estomih Mduma, Ulrika Baker, Godfrey Guga, Jan Terje Kvaløy, Dunstan R. Bishanga, Felix Bundala, Boniphace Marwa, Thomas Rutachunzibwa, Japhet Simeo, Honoratha Faustine Rutatinisibwa, Yudas Ndungile, Damas Kayera, Florence Salvatory Kalabamu, Paschal Mdoe
Healthcare vol: 12 issue: 3 first page: 319 year: 2024
doi: 10.3390/healthcare12030319
43. Documentation Practice and Associated Factors Among Nurses in Harari Regional State and Dire Dawa Administration Governmental Hospitals, Eastern Ethiopia
Takla Tamir, Biftu Geda, Bezatu Mengistie
Advances in Medical Education and Practice vol: Volume 12 first page: 453 year: 2021
doi: 10.2147/AMEP.S298675
44. Reflections on an engaged research approach to understanding patient record-keeping systems in a local clinic in Makhanda
Kirsten Kingwill, Andrew Todd, Jonathan Davy, Siphosethu Pama
African Journal of Higher Education Community Engagement vol: 1 issue: 2 first page: 1 year: 2024
doi: 10.21504/nnnh8x87
45. Audit on Effectiveness of the Dental Information System Utilisation by Dental Post-graduates and Academicians at the Department of Restorative Dentistry
P. L. Ranganayakidevi S. Palaniappan, Lim Ghee Seong
Malaysian Dental Journal vol: 47 issue: 1 first page: 8 year: 2024
doi: 10.4103/MDJ.MDJ_4_24
46. A Study at Wad Madani, Sudan: Are We Documenting Acute Ankle Fractures Effectively?
Ahmed Mohamed, Abubakr Muhammed
Cureus year: 2024
doi: 10.7759/cureus.68333
47. Exploration of clinical ethics consultation in Uganda: a case study of Uganda Cancer Institute
Mayi Mayega Nanyonga, Paul Kutyabami, Olivia Kituuka, Nelson K. Sewankambo
BMC Medical Ethics vol: 25 issue: 1 year: 2024
doi: 10.1186/s12910-024-01085-1
48. Assessing the composition of nurses in South Africa versus the WHO perspective
Fatima Abrahams, Sanjana Brijball Parumasur
Curationis vol: 48 issue: 1 year: 2025
doi: 10.4102/CURATIONIS.v48i1.2762
49. Investigating Clinical Ethics Consultation in Uganda: A Case Study at the Uganda Cancer Institute
Paul R Sewankambo
Asian Journal of Ethics in Health and Medicine vol: 4 issue: 1 first page: 28 year: 2024
doi: 10.51847/ULP3gIQWcE
50. Community-based management of acute malnutrition: Implementation quality, and staff and user satisfaction with services
Joshua A. Akuu, Moses A. Amagnya
Journal of Taibah University Medical Sciences vol: 18 issue: 5 first page: 988 year: 2023
doi: 10.1016/j.jtumed.2023.02.002
51. An exploratory study of electronic medical record implementation and recordkeeping culture: the case of hospitals in Indonesia
Md. Khalid Hossain, Juliana Sutanto, Putu Wuri Handayani, Anasthasia Agnes Haryanto, Joy Bhowmik, Viviane Frings-Hessami
BMC Health Services Research vol: 25 issue: 1 year: 2025
doi: 10.1186/s12913-025-12399-0
52. The Implementation Gap: A Socio-Technical Analysis of AI-Assisted Redaction Adoption in UK Public Authorities
Yijun Chen
Digital Government: Research and Practice vol: 7 issue: 2 first page: 1 year: 2026
doi: 10.1145/3807513
53. A critical appraisal of the quality of data submitted by sub-Saharan African cancer registries to GLOBOCAN 2020
Ereel Ayubi, Rosanna Lyus, Petra Brhlikova, Allyson M. Pollock
JRSM Open vol: 15 issue: 1 year: 2024
doi: 10.1177/20542704231217888
54. Development of strategies to enhance recordkeeping during intrapartum care in Limpopo province: A Delphi technique
Phogole C. Maesela, Johanna M. Mathibe-Neke
Health SA Gesondheid vol: 29 year: 2024
doi: 10.4102/HSAG.v29i0.2645