The Level of Competency of The Nurses in Clinical Documentation Process: The Action Plan

Clinical documentation is a fundamental component of nursing practice that supports continuity of care, patient safety, legal accountability, and interdisciplinary communication. This study assessed the level of nurses' competency in clinical documentation in the Neurological Ward. Specifically, it examined competency in terms of knowledge, skills, and attitude and determined whether significant relationships existed between nurses’ demographic profile and competency levels. A quantitative descriptive-correlational design was utilized, involving twenty (20) registered nurses selected through total sampling. Data were gathered using a validated researcher-developed questionnaire and analyzed using frequencies, percentages, weighted means, standard deviations, t-tests, and analysis of variance (ANOVA). Findings revealed that nurses demonstrated a very high level of competency in knowledge and high levels of skills and attitude. However, moderate competency was observed in the utilization of electronic health record systems and technology-related documentation processes. Statistical analysis showed no significant relationship between demographic variables and nurses’ competency in clinical documentation, leading to acceptance of the null hypothesis. The findings indicate that competency is influenced more by institutional standards, training programs, and professional practice requirements than by demographic characteristics. Based on the results, an action plan focusing on documentation enhancement, technological competency, continuing education, and quality monitoring was proposed. The study highlights the importance of strengthening clinical documentation practices to improve patient safety, quality healthcare delivery, and nursing accountability.