| Thirty-five labor and delivery nurses completed a survey asking about nursing documentation on the medical record. A feminist model was used as a basis for this study and provides a glimpse into the "socialization" of nursing. This feminist perspective forms the basis for the analysis of the data.; Results showed 71% of respondents believe that much of nursing care is never documented on the chart. Barriers to complete medical record documentation that were identified included: duplication of information in the charting systems, lack of adequate understanding of hospital documentation standards, and lack of time to chart. Finally, consequences of incomplete documentation where thought to be an increase in legal liability and a decrease in quality of patient care.; The results of this study suggests that to remedy the problem of incomplete documentation, organizations must reduce duplication of forms, move to charting by exception, and include the staff nurse in the creation of documentation forms. |
