Electronic Documentation Practice and Its Correlated Factors Among Medical-Surgical Nurses in Selected Hospitals in...

Nursing documentation provides evidence of the care delivered by clearly accounting for what occurred and when it occurred. Despite the overall importance of electronic documentation, available evidence shows significant limitations in good practice.

This study aimed to describe the electronic documentation practice and its correlated factors among medical and surgical ward nurses in four selected hospitals in Texas, USA.

The descriptive correlational study involved 379 medical-surgical nurses recruited through proportionate non-probability sampling from four hospitals in Texas, USA, with the intent of examining how socio-demographic, knowledge, attitude, and organizational factors influence electronic documentation practices. Data collected through an online questionnaire were analyzed using descriptive statistics, Spearman rho correlation, and linear regression to determine relationships and factors associated with documentation practices.

Most respondents were female (244, 64.4%), married (186, 49.1%), held a bachelor's degree (289, 76.3%), and were employed in general hospitals (254, 69%) and medical wards (290, 76.5%) for an average of 9.77 years (SD±8.51). All nurses exhibited good knowledge in areas of communication, legal protection, and patient safety, and the majority (369, 97.4%) demonstrated a favorable attitude toward the legal and clinical significance of electronic documentation. Documentation practices were strong in recording assessments, interventions, and medication administration, while lower mean scores were noted in documenting nursing diagnoses, patient education, and immediate post-care entries. Institutional supports included in-service training, operational standards, available documentation materials, and supervisory follow-up. However, more than 80% (318) reported fatigue and exhaustion, and fewer than 20% (64) indicated a lack of time and motivation for electronic documentation. Documentation practices were positively associated with educational attainment, knowledge, attitude, and organizational support (p < .01), while gender, age, income, hospital type, and years of experience showed no statistically significant correlation. Divorced nurses had poorer documentation scores compared to other marital groups.

High knowledge and favorable attitude, when supported by strong organizational systems, contribute to good documentation practices among nurses. The study recommends strengthening in-service training, addressing work-related fatigue, enhancing supervisory support and monitoring, and promoting timely documentation.