Abstract

Clients’ problems and the resultant nursing interventions, to some extent, influence the pattern of nursing documentation for the actions taken. This study examined the variations in nursing documentations with respect to clients’ diagnoses. The study was a retrospective research design. Judgemental and simple random sampling techniques were used to select documented nursing actions for 264 clients with ailments associated with medical, surgical, obstetric and infective diagnoses. The selection was from two tertiary, two secondary and two primary health care institutions in Anambra State of Nigeria. Two research questions and three null hypotheses guided the study. Checklist on Nursing Documentation in the clinical setting was used for data collection. Frequency distribution, mean score and standard deviation (SD) were used to summarize the variables. Mean score, standard deviation and Pearson Product moment correlation were used to answer the research questions while analysis of variance (ANOVA) was adopted in testing the null hypotheses at 0.01 and 0.05 levels of significance respectively. The result revealed significant correlations between nursing documentation and timeless of the documentation as well as promotion of interdisciplinary communication. The result also indicated that nursing documentation significantly differ with clients’ diagnoses.