Practice of Nurses on Patient Record Management In Tertiary Level Hospitals

Background: Patient record prescribed further state of health the patient and determines diagnosis diseases by exerting history. The study was conducted to assess practice management among nurses in a selected government hospital, Dhaka, Bangladesh. Methods: A descriptive type cross-sectional done 214 respondents following convenient methods sampling from Shaheed Suhrawardy Medical College Hospital (ShSMCH), Bangladesh January December 2020. Data were collected through face-to-face interview using pretested semi-structured questionnaire. Results: revealed that about 27% belonging 26-30 age groups mean ± SD 35.16 6.93. Most 48% diploma nursing. Out respondents, pattern nursing documentation always filled up 97%, taken manually 55%, missing files 33% confidentiality kept access for authorized ones mentioned 58%. Keeping records after death made 34.2% preservation medico-legal stored on papers narrated 90% respondents. majority 73.4% inadequate working knowledge as barrier medical history training. Conclusion: Practice Nurses may help authority identify any error care, self-evaluation, assure quality care. has an immense value if it’s possible develop electronic data record-keeping system every hospital. JOPSOM 2021; 40(2): 38-43