Abstract:

Documentation serves as a critical written record of patient care, including assessments, interventions, and outcomes. However, healthcare systems in Cameroon, including Cite Verte District Hospital in Yaoundé, face significant documentation gaps, potentially compromising patient safety and care. This study assessed the quality of nursing documentation for inpatients at this hospital. A retrospective descriptive cross-sectional design was employed, using a mixed-method approach. Quantitative data were collected from 300 patient records, while qualitative insights were gathered through interviews with nine nurses. Findings revealed inconsistencies in documentation completeness across various categories. While patient identification details were generally recorded, discrepancies existed, with 51% missing patient contact information and 0% personnel signatures. Admission records showed deficiencies in patient education (10.33%) and personnel signatures (12.33%). Vital signs documentation had critical gaps, particularly in pediatric units where BP was unrecorded (0%). Qualitative findings highlighted diverse nursing perspectives on documentation, recognizing its importance yet facing challenges such as high workload, staff shortages, inadequate training, and inconsistent practices. Proposed strategies for improvement included increasing staffing levels, implementing routine documentation audits, providing continuous training, and emphasizing the importance of accurate record-keeping. It is thus essential to address both organizational challenges and individual behaviors to ensuring complete, accurate, and high-quality nursing documentation.

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