Adherence to nursing documentation principles among Iranian nurses: A cross-sectional study

Nursing documentation is a fundamental component of safe and high-quality patient care. It serves as a key tool for continuity of care, communication among healthcare team members, and professional accountability. Despite the critical importance of nursing documentation, evidence suggests that challenges remain in adhering to standard documentation principles. This study aimed to assess compliance with nursing documentation standards among nurses at the Social Security Hospital in Gorgan, Iran. In this cross-sectional study, the study population comprised nursing records of hospitalized patients at the Social Security Hospital of Gorgan, Iran. A total of 300 patient records were selected using simple random sampling from inpatient files completed during the first six months of 2024. Data were collected using a standardized nursing documentation checklist. The findings indicated that compliance with nursing documentation principles was satisfactory across most evaluated indicators. The highest rates of deficiencies were related to the legibility of documentation (16.44%) and the recording of patient admission and discharge details (33%). In contrast, the lowest deficiency rates were observed in the use of blue or black ink for documentation (0.8%) and adherence to chronological order in nursing notes (3.44%). Additionally, deficiencies were identified in the documentation of vital signs, preoperative medications, and patient education in a subset of records. Overall, adherence to nursing documentation standards in the studied hospital was evaluated as acceptable, with a relatively low rate of documentation errors. Nevertheless, continuing education, systematic supervision, process standardization, and the implementation of electronic documentation systems are recommended to reduce existing deficiencies further and enhance documentation quality and patient safety.