TITLE:
Survey on Nursing Documents in Use on Patients with Heart Diseases at the Regional Hospital Bamenda
AUTHORS:
Marceline Singam Foba, Kenneth Navti Lifoter, Mary Bi Suh Atanga
KEYWORDS:
Nursing Documents, Documentation, Heart Disease, Effective Patient Care
JOURNAL NAME:
Journal of Biosciences and Medicines,
Vol.13 No.7,
July
11,
2025
ABSTRACT: Introduction: Nursing documentation is fundamental to clinical practice, ensuring patient safety, continuity of care, and fostering interprofessional collaboration. Documenting appropriately, thoroughly and accurately is a nurse’s legal and ethical responsibility. Concerns about care can easily be brought into question if a nurse’s documentation does not represent a comprehensive picture of care that was delivered to a client. Nursing documentation is central to clinical decision-making and continuity of care, particularly for chronic conditions like heart disease. Accurate documentation allows healthcare providers to track a patient’s progress, adjust care plans, and ensure that all team members are aware of the latest updates in the patient’s treatment. Objectives: The objectives were, to identify the existing documents used on patients with heart diseases, to assess the frequency of use of documents on patients with heart diseases, to identify the reasons for effective use of documents on patients with heart diseases and to identify the reasons for neglect in the use of nursing documents on patients with heart diseases at the Regional Hospital Bamenda (RHB). Methods: A cross-sectional descriptive study design was used for this survey. A purposive sampling technique was used to recruit the nurse supervisors, while a convenient sampling method was used to recruit staff nurses into the study population. A total of 161 nurses (50 supervisors and 111 staff nurses) were recruited. Data was collected using structured questionnaires as the primary instrument and a participant observation checklist to assess the use of documents on patients with heart diseases. Data was analyzed using SPSS version 26. Results: The demographic characteristics of 147 participants reveal a young, predominantly female, educated nursing workforce who are serving as staff nurses and nurse supervisors. Most of them have 6 - 10 years of experience. His study presents documents reported by nurses with inconsistencies and significant gaps in the availability of crucial nursing documents, such as patient assessment documents, indicated as not available to 128 (87.1%) participants. The study revealed a generally positive perception among nurses regarding the routine use of nursing documents, with 81.6% of nurses indicating using them regularly for the care of patients with heart disease (HD). The study shows that 83% of participants indicated workload as one of the reasons for neglecting nursing documentation. Conclusion: The study concluded that documentation practices at the Regional Hospital Bamenda were poorly implemented, as there were no necessary documents available for documentation and a staff shortage. There is also an indication of a lack of follow-up on documentation practices by nurses at the hospital, which should ensure effective management and quality of care for patients with heart diseases.