Record keeping: self-reported attitudes, knowledge and practice behaviours of nurses in selected Cape Town hospitals

  • Johann M Olivier
  • Una Kyriacos
Keywords: Record keeping in nursing, nursing documentation, nursing process, nursing record

Abstract

South African law holds nurses accountable for their acts and omissions and all documentation pertaining to patient care may serve as evidence in a court of law or at South African Nursing Council (SANC) hearings. Documentation can confirm or refute negligence and therefore should be an accurate and current reflection of what happened to the patient, particularly as litigation often arises long after care was rendered. The objective of this study was describe the self-reported attitudes towards, knowledge of and practice behaviours of nurses, and the association between these factors and selected variables (category of nurse, gender, hospital sector, years of experience after registration/enrolment, day/night shift and practice discipline) relative to record keeping. This is a short summary of a Master of Science degree research project.

Author Biographies

Johann M Olivier
MSc Nursing, BA(Cur)HSM&HSE, Dip Nursing RN RM RCHN RPN
Una Kyriacos
MSc Nursing, BCur I et A, RGN, RM, RIntCN Oph N
Section
Original Research