Nursing documentation: Experience of the use of the nursing process model in selected hospitals in Ibadan, Oyo State, Nigeria

The descriptive study was conducted to determine the extent of utilization of the nursing process for documentation of nursing care in three selected hospitals, Ibadan, Nigeria. One hundred fifty nurses and 115 discharged clients records were selected from the hospitals. Questionnaires and checklists were used to collect data. Utilization of nursing process for care was 100%, 73.6% and 34.8% in the three hospitals. Nurses encountered difficulties in history taking, formulation of nursing diagnoses, objectives, nursing orders and evaluation. Most nurses disagreed or were undecided with the use of authorized abbreviations and symbols (34.3%, 40.3% and 69.5%), recording errors that occurred during care (37.1%, 56.1% and 52.2%) and inclusion of change in clients condition (54.3%, 56.1% and 73.8%). Most nurses appreciated the significance of documentation. Lack of time, knowledge and need for extensive writing are the major barriers against documentation. Seventy-seven point four per cent of the 115 clients records from one hospital showed evidence of documentation, no evidence from the other two. Study findings have implications for continuing professional education, practice and supervision.