ABSTRACT
Documentation is a basic nursing service leading to transparency and efficiency in implementation in the health care sector and hospitals, especially in these uncertain times. The standard of nursing care provided to clients in hospitals is linked to the quality of documentation followed in the hospitals. It forms the basis on which to audit and improve medical care. The purpose of this paper is to identify socio-demographic characteristics of nurses at government hospitals and to assess nurses’ perception regarding documentation based on six selected components. For this, a cross-sectional, descriptive study was conducted between May 2017 and May 2018. Primary data was collected from nurses of two district and two sub-district hospitals to assess nurses’ perception towards documentation carried out at select government hospitals of North and South District of Goa. A total of 114 nurses participated in the study. It was found 52% of the nurses were satisfied with the maintenance of records, 30% were very satisfied, 14% remained neutral. While 4% were dissatisfied, none were very dissatisfied.
