Nurses’ Documentation Practices and Patient Safety in Primary Healthcare Facilities in Calabar South Local Government Area, Cross River State, Nigeria

Ensuring patient safety in primary healthcare facilities is a pressing issue, often stemming from a lack of adequate resources, medication mishaps, poor record-keeping, lapses in infection control, and ineffective clinical practices. These hurdles can put patients at risk of preventable harm, complications, and negative health outcomes, ultimately compromising the quality and effectiveness of the services provided. Thus, this research aims to examine nurses’ documentation practices and patient safety in primary healthcare facilities in Calabar South Local Government Area, Cross River State, Nigeria. The study adopted descriptive survey research design. Two hypotheses were formulated and tested at 0.05 level of significance. Simple random sampling technique was used to select 100 nurses and 343 patients that constituted the sample. The instruments for data collection were Nurses Documentation Practices Questionnaire (NDPQ) and Patient Safety Questionnaire (PSQ). The reliability of the instrument was established using split-half method which yielded indices ranged from 0.73 and 0.87 respectively. Consequently, the instruments were found to be adequately reliable for use in the study. Analysis of variance (ANOVA) was used to analyse the collected and prepared data for all the hypotheses; at 0.5 level of significance. The result revealed that timeliness of documentation and use of electronic health records had significant influence on patient safety. It was recommended among others that healthcare institutions should implement strict policies for timely documentation, ensuring that healthcare professionals accurately and promptly record patient information after every relevant clinical encounter.

Keywords: Nurses Documentation Practices, Timeliness of Documentation, Use of Electronic Health Records, Patient Safety in Primary Healthcare Facilities.