Nursing is a profession that requires specialized skill and knowledge pertinent to the duties to be executed. There is currently considerable interest throughout the world within the health care sector to increase the quality of nursing documentation and nursing terminology. The present study was conducted to assess the practices of staff nurses regarding nursing documentation. In this study 150 sample of the nurses who are working in the ICUs and CCU at MMIMS&R Hospital was collected by purposive Sampling technique. Data was collected through Structured Observational Checklist.The result of study showed that mean percentage of patient profile is (99.16%), general consideration is (97.14%) and need based care is (76.33%). Mean±SD of patient profile is (11.9) ±(0.55). Vital sign (10.60) ±(2.06) general consideration(6.8) ±(0.7) and the mean of the practices of staff nurses regarding nursing documentation was 61.99+- 8.30 with median of 65 and mode was 70. Further In relation to area of work and work experience significant association was seen with the practice of staff nurses as p value <0.05. The study concluded that Staff Nurses had good practices (75.59) regarding nursing documentation followed by poor practices (24.41%).

Nursing is a profession that requires specialized skill and knowledge pertinent to the duties to be executed. There is currently considerable interest throughout the world within the health care sector to increase the quality of nursing documentation and nursing terminology. The present study was conducted to assess the practices of staff nurses regarding nursing documentation. In this study 150 sample of the nurses who are working in the ICUs and CCU at MMIMS&R Hospital was collected by purposive Sampling technique. Data was collected through Structured Observational Checklist.The result of study showed that mean percentage of patient profile is (99.16%), general consideration is (97.14%) and need based care is (76.33%). Mean±SD of patient profile is (11.9) ±(0.55). Vital sign (10.60) ±(2.06) general consideration(6.8) ±(0.7) and the mean of the practices of staff nurses regarding nursing documentation was 61.99+- 8.30 with median of 65 and mode was 70. Further In relation to area of work and work experience significant association was seen with the practice of staff nurses as p value <0.05. The study concluded that Staff Nurses had good practices (75.59) regarding nursing documentation followed by poor practices (24.41%).