Nursing Documentation: A survey of Hemodialysis Documentation Status at Kenyatta National Hospital’s Renal Unit
Abstract
Background: Documentation provides communication regarding the care of clients and acts as a formal legal
document giving details of a client’s management. Throughout the world it is accepted that if a procedure is not
documented it is not done thus documentation should be complete and accurate. Timely, accurate and complete
documentation helps the patient secure better care and protects the nurse from litigation.
Objective: To assess the completeness and accuracy of nursing documentation at Kenyatta National Hospital’s
renal unit.
Design: Cross-sectional descriptive study.
Results:77.4% of the charts had patient numbers indicated. All the charts did not have laboratory tests or
results indicated. 95.7% of the charts did not have instructions to the patients on discharge. Less than 30% of
the charts were complete and accurate.
Conclusion: Documentation was not accurate nor complete.
Recommendation: The nurses working in the renal unit should have continuous medical education on
documentation and there should be audits done on documentation. Further research is also recommended on
nursing documentation.
