Evaluation of Documentation Precision in Pediatric Intensive Care Records Following Digital Adaptation

African Journal of Nursing and Midwifery | Vol. 14, No. 9, September 2026 | pp. 133–142

DOI: 10.46882/2026/AJNM/000147

Original Research Article

Title: Evaluation of Documentation Precision in Pediatric Intensive Care Records Following Digital Adaptation

Names of Authors: Funmilayo T. Adebayo¹, Chisomo T. Banda²

Authors’ Affiliations:
¹Nursing Services Department, University College Hospital, Ibadan, Nigeria
²Kamuzu College of Nursing, University of Malawi, Lilongwe, Malawi

Abstract:
The clinical migration from analog charting to electronic healthcare records (EHR) frequently creates unexpected documentation omissions in critical care settings during early adoption windows. This retrospective audit evaluated nursing record precision and completeness within a pediatric intensive care unit (PICU) six months following digital implementation. A validated 45-item chart evaluation checklist was applied to 280 randomly selected electronic pediatric files. Statistical analyses relied on paired t-tests and descriptive metrics. The audit revealed that while biometric telemetry data and intake-output monitoring indices were highly complete (92.5%), structured nursing diagnoses and localized pain assessment scores were omitted in 41.8% of the records. Medication administration recording errors were significantly higher during emergency resuscitations compared to routine care intervals (p < 0.005). Nurses cited system layout complexities (74.3%) and insufficient terminal availability at the bedside (62.1%) as prime contributors to delayed input behaviors. Continuous simulation-based documentation exercises and software shortcut optimizations are necessary to secure robust clinical record data in intensive environments.

Keywords: Pediatric Intensive Care; Electronic Health Records; Clinical Documentation; Nursing Audits; Data Completeness; Patient Safety.

Manuscript Timeline: Received June 20, 2026; Revised August 11, 2026; Accepted August 28, 2026; Published September 09, 2026.

Citation: Adebayo, F. T., & Banda, C. T. (2026). Evaluation of Documentation Precision in Pediatric Intensive Care Records Following Digital Adaptation. African Journal of Nursing and Midwifery, 14(9), 133–142. DOI: 10.46882/2026/AJNM/000147

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