title: An Audit of Nursing Documentation at Three Public Hospitals in Jamaica.
abstract: Nursing documentation provides an important indicator of the quality of care provided for hospitalized patients. This study assessed the quality of nursing documentation on medical wards at three hospitals in Jamaica.
  
  
  
  This cross-sectional study audited a multilevel stratified sample of 245 patient records from three type B hospitals. An audit instrument which assessed nursing documentation of client history, biological data, client assessment, nursing standards, discharge planning, and teaching facilitated data collection. Descriptive statistics were conducted using IBM SPSS, Version 19 (IBM Inc., Armonk, NY, USA).
  
  
  
  Records from three hospitals (Hospital 1, n = 119, 48.6%; Hospital 2, n = 56, 22.9%; Hospital 3, n = 70, 28.6%) were audited. Documented evidence of the patient's chief complaint (81.6%), history of present illness (78.8%), past health (79.2%), and family health (11.0%) were noted; however, less than a third of the dockets audited recorded adequate assessment data (e.g., occupation or living accommodations of patients). The audit noted 90% of records had a physical assessment completed within 24 hr of admission and entries timed, dated, and signed by a nurse. Less than 5% of dockets had evidence of patient teaching, and 13.5% had documented evidence of discharge planning conducted within 72 hr of admission.
  
  
  
  This study highlights the weakness in nursing documentation and the need for increased training and continued monitoring of nursing documentation at the hospitals studied. Additional research regarding the factors that affect nursing documentation practice could prove useful.
  
  
  
  The study provides valuable information for the development of strategic risk management programs geared at improving the quality of care delivered to clients and presents an opportunity for nurse leaders to implement structured interventions geared at improving nursing documentation in Jamaica. In light of Jamaica's epidemiologic transition of chronic diseases, gaps in nurses' documentation of client assessment, patient teaching, and discharge planning should be addressed with urgency. Patient teaching and discharge planning enable the clients to participate more effectively in their health maintenance process.
authors.affiliation: Lecturer, The University of the West Indies School of Nursing, Mona Kingston, Jamacia and Barry University, Miami, FL, USA. jaslindo@hotmail.com, jlindo@barry.edu.
authors.forename: Jascinth
authors.initials: J
authors.lastname: Lindo
authors.affiliation: Research Assistant, The University of the West Indies School of Nursing, Mona, Kingston, Jamaica.
authors.forename: Rosain
authors.initials: R
authors.lastname: Stennett
authors.affiliation: Senior Lecturer, Knox Community College, Spalding Clarendon, Jamaica West Indies.
authors.forename: Kayon
authors.initials: K
authors.lastname: Stephenson-Wilson
authors.affiliation: Senior Lecturer, Excelsior Community College, Kingston, Jamaica.
authors.forename: Kerry Ann
authors.initials: KA
authors.lastname: Barrett
authors.affiliation: Campus Director, Browns Town Community College, Saint Ann, Jamaica.
authors.forename: Donna
authors.initials: D
authors.lastname: Bunnaman
authors.affiliation: Lecturer, The University of the West Indies School of Nursing, Mona, Kingston, Jamaica.
authors.forename: Pauline
authors.initials: P
authors.lastname: Anderson-Johnson
authors.affiliation: Assistant Lecturer, The University of the West Indies School of Nursing, Mona, Saint James, Jamaica.
authors.forename: Veronica
authors.initials: V
authors.lastname: Waugh-Brown
authors.affiliation: Lecturer, The University of the West Indies School of Nursing, Mona, Saint James, Jamaica.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Wint
mesh_terms: D003430:Cross-Sectional Studies; D006779:Hospitals, Public; D006801:Humans; D007563:Jamaica; D009731:Nursing Audit; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital
keywords: Jamaica; nursing documentation; nursing practice