https://gprjournals.org/journals/index.php/jhmcs <p><strong>Journal of Health, Medicine, and Clinical Studies (JHMCS)</strong> is a peer-reviewed, interdisciplinary research, and international journal published by GPR Journals. The scope of this journal include, but not limited to Exercise &amp; Self-care, Health Care Practices, Health Diagnosis, Mental Health, Nurse Training &amp; Practice, Occupational Health, Physical Health, Public Health, Surgery, Technology in Medicine Manufacturing, etc. Additionally, this journal covers interdisciplinary research across the topics on Clinical Research, Health Policies as well as emerging technological development in medicine. JHMCS is rigorously examined by qualified doctors and nurses to maintain its reliability and authority. This journal is recommended for all topics relating to health, medicine, and clinical studies which are then published online and can also be availed as hard copies upon author’s request. Papers can be submitted via email to <a href="mailto:journals@gprjournals.org">journals@gprjournals.org</a> or <a href="https://gprjournals.org/online-submission/">online submission</a>.</p> en-US <p><em>The authors retain the copyright and grant this journal right of first publication. This license allows other people to freely share and adapt the work but must give appropriate credit, provide a link to the license, and indicate if changes were made. They may do so in any reasonable manner, but not in any way that suggests the licensor endorses them or their use.</em></p> journals@gprjournals.org (Chief Editor) journals@gprjournals.org (admin) Mon, 01 Sep 2025 14:25:55 +0000 OJS 3.3.0.10 http://blogs.law.harvard.edu/tech/rss 60 https://gprjournals.org/journals/index.php/jhmcs/article/view/405 <p><strong>Aim</strong>: 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.</p> <p><strong>Methods</strong>: 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.</p> <p><strong>Results</strong>: 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.</p> <p><strong>Conclusions</strong>: 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.</p> <p><strong>Recommendations:</strong> 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). &nbsp;</p> <p>&nbsp;</p> Christine Mwikali Musee, Miriam Wagoro Copyright (c) 2025 Christine Mwikali Musee, Miriam Wagoro https://creativecommons.org/licenses/by/4.0 https://gprjournals.org/journals/index.php/jhmcs/article/view/405 Mon, 01 Sep 2025 00:00:00 +0000