Evaluation of Quality of Documentation Practices Among Doctors and Nurses in Kenyatta National Hospital, Kenya

Aim: This study aimed to assess the quality of healthcare documentation, identify influencing factors, and evaluate the use of structured standardized approaches among health providers at Kenyatta National Hospital. Methods: A cross-sectional study was conducted among 320 healthcare providers (277 nurses and 43 doctors) who had worked in the inpatient setting for at least six months. Data were collected using semi-structured questionnaires, interviews, and focus group discussions, and analyzed using SPSS with Chi-Square tests (p ≤ 0.05) and thematic analysis for qualitative data. Results: Of the 320 respondents (100% response rate), most were female nurses with a diploma, with a mean age of 32 years. While the majority rated the quality of documentation as ‘good,’ factors such as knowledge, teamwork, staffing ratios, availability of structured tools (e.g., SBAR), and support supervision significantly influenced documentation practices (p ≤ 0.05). Key challenges included staff shortages, inadequate resources, and limited patient involvement in documentation. Conclusions: Although the quality of documentation was generally rated as good, sustained improvement requires investment in staff training, adequate staffing ratios, supportive supervision, teamwork, and wider adoption of structured tools such as SBAR. Recommendations: Further training is recommended, better staffing ratios, teamwork, support-supervision, positive attitude and the SBAR tool of documentation/communication needs to be adopted, supervised and monitored (perhaps through champions).