FACTORS INFLUENCING DOCUMENTATION OF TREATMENT AMONG NURSES AT SOROTI REGIONAL REFERRAL HOSPITAL-SOROTI CITY. A CROSS-SECTIONAL STUDY.

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Background Nursing documentation reflects the entire process of providing direct nursing care to patients. Nursing documentation that is clear, accessible, and accurate is an essential element of quality, safe, and evidence-based nursing care. The study aimed to identify factors influencing the documentation of treatment among nurses at Soroti Regional Referral Hospital. Methodology The researcher used a descriptive cross-sectional study employing quantitative techniques of data collection and a total of 30 nurses working in different wards at SRRH were selected using the purposive sampling method. Data was analyzed by Microsoft Excel and presented in tables, pie charts, and tables. Results 30 respondents participated in this study, 22 females and 8 males. The majority of the respondents were 25-29 years old, while those between 20-24 and 30-35 years old were the minority. The study found that 93.3% of nurses did not document patient care, 93.3% did not have the necessary documentation materials, and 60% of the nurses reported working alone in a shift. Conclusion Inadequate essential documentation materials and a low number of nurses working per shift were found as the major reasons for poor documentation of treatment among nurses in SRRH. Recommendation The hospital administration should provide adequate documentation materials and lobby for more nurses to boost the number of those currently employed at the facility.

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