Mabunda Nkhensani F, Masondo Itumeleng G, Mokoena-de Beer Andile G
Department of Nursing, Faculty of Health Sciences, Sefako Makgatho Health Science University, Pretoria.
Curationis. 2025 May 22;48(1):e1-e8. doi: 10.4102/curationis.v48i1.2737.
Nursing documentation is an integral part of nursing practice that is planned and delivered to individual patients by qualified nurses to provide evidence of the standard of care. The quality of nursing documentation is the inscriptions of all categories of nurses, including students, to record nursing care to facilitate continuity of care and patients' safety.
This study aimed to explore and describe the psychiatric nurses' comprehension of the quality of nursing documentation in the selected mental health institution in Gauteng province.
The qualitative, explorative-descriptive and contextual design was used. The target population was all nurses directly involved in patient care. Individual face-to-face semistructured interviews were used to collect data. Braun and Clarke's (2022) six steps of the thematic descriptive analysis method were adopted to allow the second author to identify themes and recapitulate data.
The two themes and subthemes that emerged from the findings include nurses' understanding of the impact of quality documentation on patient care outcomes and support needs to improve the quality of nursing documentation.
Understanding the quality of nursing documentation is an essential element for producing continuous clinical communication and reflection on the everyday activities of nursing care that are planned and implemented on individual patients' progress reports.Contribution: The study contributes to nursing practice, as its results can be used to measure the quality of the primary source of clinical information improvements, allowing healthcare professionals to communicate with each other about a patient's care.
护理记录是护理实践的一个组成部分，由合格护士为个体患者制定并提供，以证明护理标准。护理记录的质量是所有类别护士（包括学生）记录护理情况的记录，以促进护理的连续性和患者安全。
本研究旨在探讨和描述豪登省选定精神卫生机构中精神科护士对护理记录质量的理解。
采用定性、探索性描述性和情境设计。目标人群是所有直接参与患者护理的护士。使用个人面对面半结构式访谈收集数据。采用布劳恩和克拉克（2022年）的主题描述性分析方法的六个步骤，让第二作者识别主题并概括数据。
研究结果中出现的两个主题和子主题包括护士对高质量记录对患者护理结果的影响的理解以及提高护理记录质量的支持需求。
理解护理记录的质量是产生持续临床沟通以及对根据个体患者进展报告计划和实施的日常护理活动进行反思的关键要素。贡献：该研究对护理实践有贡献，因为其结果可用于衡量临床信息改进主要来源的质量，使医疗保健专业人员能够就患者护理相互沟通。
