Title : Nurses’ compliance with principles of documentation: A descriptive, short observational study in oman

Background: Nursing documentation is a critical component of patient care, communication, and legal accountability. Inadequate documentation compromises patient safety and quality of care.
Objective: To assess nurses’ compliance with principles of nursing documentation. To correlate the demographic characteristics with the quality of nursing documentation.  
Methods: A descriptive, quantitative observational study was conducted using patient records documented by nurses over a defined period in multicenter at South Sharqyiah. Documentation was assessed using a structured audit checklist based on established documentation principles. Descriptive and inferential statistics were used for analysis.
Results: A total of 273 nurses were observed for their documentation post care delivery for a defined period. Overall compliance with documentation principles was moderate. . The study findings indicated varying levels of compliance with documentation principles. High compliance was observed in general structure and quality of documentation such as’’ Document is entered by staff who delivered the care’’ (mean=1.99,SD=0.12) ; Document is stated in specific, concise, accurate manner ( mean=1.96, SD=0.20) , while The lowest scores in the entire audit were found in Communication with client's family, providing Health education, psychosocial support, and procedural notes contain details of intervention (1.46,1.39,1.38, 1. ) retrospectively. It was also observed that ‘’ receiving note ‘’scored low scores (1.44) . The quantitative data also illustrates that only 78 (29%) of nurses had in service training related to nursing documentation.  Significant associations were found between quality of documentation and demographic characteristics include Nationality, education, institution category (p < 0.05).
Conclusion: Nurses’ compliance with documentation principles was suboptimal in several areas. Strengthening training, supervision, and standardized documentation tools is recommended to improve documentation quality and patient safety.

Keywords: Nursing documentation, compliance, observational study, cross-sectional, patient records

Dr. Jane Doe is an epidemiologist specializing in infectious disease research and outbreak response. She holds a PhD in Epidemiology from Harvard University and an MPH from Johns Hopkins University. Dr. Doe has worked with WHO and CDC on global health initiatives and has published extensively on zoonotic diseases. She is currently the Director of the Global Infectious Disease Program at the University of California, San Francisco.