Variables

Documentation status

Patient assessment

NO, n (%)

P, n (%)

FD, n (%)

NA, n (%)

History taking (subjective data)

History taking

413 (80.5)

73 (14.2)

27 (5.3)

-

Physical examination (objective data)

Vital observations

243 (48.0)

227 (44.0)

43 (8.0)

-

Evidence of physical examination

407 (79.0)

72 (14.0)

34 (7.0)

-

Problem identification

Problem stated

435 (85.0)

70 (14.0)

8 (1.0)

-

Identification of the related factors

471 (91.8)

41 (8.0)

1 (0.2)

-

Documentation of signs and symptoms

470 (91.6)

41 (8.0)

2 (0.4)

-

Documentation of nursing concerns

454 (88.5)

55 (10.7)

4 (0.8)

-

Planning

Documented short-term goals

443 (86.4)

66 (12.9)

4 (0.8)

-

Documented long-term goals

476 (92.8)

36 (7.0)

1 (0.2)

-

Expected outcomes

469 (91)

44 (9)

-

Implementation

Documented implementation

420 (81.9)

63 (12.3)

30 (5.8)

--

Rationale for implementation

471 (91.8)

42 (8.2)

-

Evaluation of expected outcomes

455 (88.7)

43 (8.4)

15 (2.9)

-

Completion of charts

Observation charts

135 (26.3)

290 (56.5)

88 (17.2)

-

Treatment charts

186 (36.3)

327 (63.7)

-

-

Input and output charts

338 (65.9)

175 (34.1)

Completed antenatal records

69 (13.5)

18 (3.5)

35 (6.8)

391 (76.2)

Completed partograph

48 (9.4)

14 (2.7)

17 (3.3)

434 (84.6)

Completed postnatal forms

31 (6.0)

17 (3.3)

25 (4.9)

440 (85.8)

Date of entry indicated

43 (8.0)

81 (16.0)

389 (76.0)

-

Integration of patient care

Evidence of integration of patient care (use of nurses’, doctors’, and patients’ information in decision making)

249 (48.5)

232 (45.2)

32 (6.2)

-

COMPLETION OF CHARTS

The title of the nurse indicated

465 (90.3)

24 (4.7)

24 (4.7)

-

Erasing errors (single line)

16 (3.1)

8 (1.6)

4 (0.8)

485 (94.5)