13,14 There is no way to prove care was provided without completed documentation,
2,15 as many studies indicated globally, most of the nurses’ actions are either not documented or not properly documented.
2,6,16,17 In Africa as well as Ethiopia, the act of nursing documentation remains challenging due to lack of training, resources, comprehensive nursing education (CNE), time, high nurse-to-patient ratio, poor knowledge, and attitude.
Nurses play an important role in the care of patients and what they put into writing determines the standard and quality of care rendered to the patient.
2 Documentation is the tip of the iceberg of patient care issues that could expose caregivers to medico-legal suits and other forms of disciplinary action.