Evaluation of Nursing Documentation Practices and Its Implication on Patient Care Among Nurses and Midwives in General Hospital Gusau, Zamfara State

Abstract

This study evaluates nursing documentation practices and their implications on patient care among nurses and midwives at General Hospital Gusau, Zamfara State. Nursing documentation plays a critical role in ensuring high-quality care, fostering communication, supporting legal and professional standards, and promoting patient safety. However, poor documentation practices often due to reliance on paper records, inadequate training, and workload pose significant challenges to healthcare delivery. The study employed a descriptive cross-sectional design, with 105 respondents selected through simple random sampling from a population of 290 nurses and midwives. Data were collected using a validated, self-structured questionnaire and analyzed using descriptive statistics. The results show that most participants have a good understanding of the importance of documentation, recognizing its role in communication, risk identification, and continuity of care. While a majority reported consistent documentation of patient care, gaps remain in the timeliness and comprehensiveness of entries. Respondents emphasized the need for regular training, orientation, and the integration of electronic documentation systems as key strategies for improvement. The findings highlight the critical need to strengthen nursing documentation practices to support effective care delivery, patient safety, and professional accountability. This study provides insight for healthcare administrators, policymakers, and educators aiming to enhance nursing documentation and, by extension, improve patient outcomes.