Challenges for Improving Nursing Documentation at PHCs, Riyadh, Saudi Arabia

Background: Family and Community Medicine Department is providing quality primary health care service through its 16 peripherals PHCs that are providing direct patients care and performing documentation on patients' charts on electronic nursing records (Rabet system). Each of these peripherals is taking a sample of 10% of their total patient census per session, subject to submission every Sunday of the week for audit for compliance to completeness. Nursing documentation is a legal record and communication for continuity of care; it is an important function of professional nursing practice. The project aimed to examine the current practice of nursing documentation and develop a project for improvement. The project was conducted from January to July 2024. It is based on the fundamental concepts of assessment and documentation.Methods: Nursing documentation uses electronic nursing records (Rabet system) in entering data for each patient and this is the documentation-guiding framework. In this initiative, we approached the problem by multiple interventions. The memo released by the Director of Nursing dated August 02, 2023, asking all the staff nurses to follow strict compliance to documentation completeness criteria in order to improve documentation practice. An audit was continuously conducted weekly from January up to July 2024, followed by a monthly meeting to all Head Nurses citing the full adherence of each staff. Per peripherals there are two staff nurses who are covering the screening area for documentation and with 16 peripherals; two of these peripherals are having 24hrs duty (6 sessions), while the other peripherals they are having regular 3 sessions. Verbal counseling to those staff who are neglecting to complete the documentation process. The nursing documentation completion rates before the implementation of the action plan /intervention were compared with the completion rates after the implementation. The increase in nursing documentation completion rates in post-intervention implementation was attributed to the effectiveness of the intervention.Results: The nursing documentation completion rates during the months when the action plan was still being developed were notably low, with January 2024 at 51%, February at 65%, and March at 81%. After the implementation of the intervention strategy, the completion rates improved, reaching 90% in April 2024, 91% in May and June, and 96% in July 2024. This demonstrates the effectiveness of the intervention implementation in improving nursing documentation compliance.Conclusion: The nursing Documentation Completeness Project had a significant impact on improving the completion rate of nursing documentation. The goal of the project is to guarantee that patient information is regularly and accurately captured by standardizing and optimizing nursing documentation procedures. This project enhances clinical decision-making, lowers the risk of errors, fosters continuity of care, and increases communication between medical personnel.Recommendations: Adopting the Nursing Documentation Completeness Project is suggested as an essential strategy for improving the standard of nursing documentation completeness for effective patient care.