n Africa Journal of Nursing and Midwifery - The quality of nursing documentation in a hospital in Rwanda

Volume 8 Number 1
  • ISSN : 1682-5055


This study was conducted at a hospital in Kigali, Rwanda. The purpose of the study was to evaluate the quality of nursing care documentation of hospitalised patients and its effectiveness in one hospital in Rwanda. The sample included 45 patient document files. Twenty files were sampled from medical departments and twenty-five were selected from surgical departments. A quality measurement checklist was used to assess the data. The data showed that nurses focus on the medical prescription charts more than they did on the nursing care plans. According to the research findings, just under half (48.7%) of the records were kept in permanent form. It was found that large percentages (68%) of patients' vital signs were not taken on admission. The study found that the patients' pupil reaction, skin colour and mental states were not recorded on admission.

It was found in this study that all (100%) of the documents contained patients' assessments of their basic needs within 24 hours of their admission to the hospital. This was despite the large number of the emergency cases admitted to the hospital.
The patients' parameters were not taken regularly nor were they recorded on the observation charts. The data further showed that there was no effectiveness of the patients' documents since they were neither properly completed nor utilised.

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