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Nursing documentation can be either paper based or electronic based documentation. Paper based documentation has been described not meet the required standards. We argued the standards of nursing documentation that should be met including completeness, clearing, and concision. John Eric D. This study was conducted for the purpose of determining the nursing documentation of the medical, surgical, and obstetrical wards of a secondary private hospital in Rizal. The level of the quality of documentation includes completeness, accuracy, timing, and permanence.

Specifically, this paper sought to determine the demographic profile of the respondents in terms of age, sex, and education; the level of quality of nursing documentation; and the significant relationship between the demographic variables and the overall quality of the nursing documentation. The respondents of the study were nurses from Antipolo City Medical Hospital, which is a secondary private hospital. Purposive sampling or judgmental sampling method and a descriptive correlational method through an adapted Nursing Documentation Audit Tool developed by Center's Quality Assurance Committee, Wroten and Associates, Inc.

The questionnaire was divided into two parts: the first part contains the demographic profile of the respondents and the second part consists of a twenty-one 21 item assessment tool that will determine the level of quality of documentation. The majority of respondents belong to the young adult group years old; are female and are registered nurses only. Based on the study, the Level of the Quality of Documentation of the Respondents gathered arithmetic mean or average of Moreover, the study revealed that there was a significant relationship between the overall quality of nursing documentation and the demographic profile of the respondents.