Nursing documentation for every patient (n = 316) |
Always |
188 |
59.5 |
Sometimes |
118 |
37.3 |
Rarely |
8 |
2.5 |
Never |
2 |
0.6 |
Time preference to document a care (n = 316) |
Any time when convenient |
118 |
37.3 |
Immediately or soon after care rendered |
160 |
50.6 |
At the end of shift hours |
36 |
11.4 |
I don’t know |
2 |
0.6 |
Ways to keep confidentiality of record (n = 316) |
Access for authorized ones only |
214 |
54 |
Protect computer pass words |
42 |
10.6 |
Obtain informed consent |
74 |
18.7 |
Confidentiality after death |
31 |
7.8 |
I don’t know |
35 |
8.8 |
Read colleague’s notes (n = 316) |
Yes |
230 |
72.8 |
No |
86 |
27.2 |
Colleague’s notes fulfill standard (n = 230) |
Yes |
100 |
43.5 |
No |
130 |
56.5 |
Documents education or advice (n = 316) |
Always |
116 |
36.7 |
Sometimes |
109 |
34.5 |
Rarely |
34 |
10.8 |
Never |
57 |
18 |
Uses computerized documentation system(n = 316) |
Yes |
54 |
17.1 |
No |
262 |
82.9 |
Reports any medical error voluntarily(n = 316) |
Yes |
225 |
71.2 |
No |
91 |
28.8 |
Way of error recording(n = 225) |
No words like” error” or “mistake” |
86 |
32.5 |
Facts only |
132 |
49.8 |
I don’t know |
47 |
17.7 |
Documents patient response to care (n = 316) |
Yes |
187 |
59.2 |
No |
129 |
40.8 |