A Survey-Based Approach to Streamlining Nursing Documentation Practices at Hospital Settings





Introduction: The meticulous recording of patient information not only facilitates communication among healthcare providers but also plays a crucial role in maintaining patient safety. The manual nature of charting poses a risk of errors and can be time-consuming for nurses. Objective: The study aim to explore the perspective of nursing observational charts practice at Pahang’s government hospitals in 2023. Method: This is a cross-sectional survey conducted among nurses across various hospitals in 2-month duration. After randomisation, nurses meeting the inclusion and exclusion criteria were enrolled in the study. Descriptive and inferential statistics were computed to analyse the data. Result: A total of 582 nurses responded, the study found on average, 8.1 ± 2.7 SD standard charts were required during admission, and 3.0 ± 1.9 SD additional charts may required to supplement the standard charts per patient. Discussion: The study revealed that the adoption of a combined chart was associated with a 2.2 times improvement in the ease of nursing documentation practices.  Conclusion: Having all relevant information in one place could reduce the need for nurses to navigate through multiple forms.


Observation Chart, Nurses Efficiency, Patient’s Documentation, Streamlining Nursing Practice


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How to Cite

Idris, I. bin . (2024). A Survey-Based Approach to Streamlining Nursing Documentation Practices at Hospital Settings. Malaysian Journal of Medical Research (MJMR), 8(1), 1-8. https://doi.org/10.31674/mjmr.2024.v08i01.001