What are the documentation preferences of clinical instructors in terms of, Subjective Data, Objective Data, Analysis of the Problem, Plan of Care, Interventions and Evaluation. And finally, was there a significant difference in the documentation preference of Level Ill Clinical Instructors when grouped according to profile variables? The researchers conducted this thesis to eliminate the confusions caused by different documentation preferences and to avoid the errors it would cause.

Moreover, the researchers University of Perpetual Help System -Content aimed to develop a standardized style of formulating documentation unique to this university, to exhibit the competence and excellence of the University of Perpetual Help System, Banana in rendering high quality care in the nursing practice and lovably competent nursing education. Methodology This study utilized a non-experimental descriptive correlation research design to test the relationship between the demographic profiles of clinical instructors and their documentation preference.

A survey method was employed to gather the self report of the respondents with the use of questionnaire. Findings The demographic profile of the Clinical Instructors shows that of the 41 respondents, 15 or 36. 58% belonged to age group 30-40. There are 28 or 68. 29% of the 41 Clinical Instructors who were female. Twenty four or 58. 4% graduated from Bachelor of Science in Nursing Program on the year 2000 and below. Twenty four or 58. 54% had a clinical experience of 5 years and less. Thirty one or 75. 61% answered that they only had teaching experience of 5 years and less.

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In assessing for subjective data, the respondents preferred to include the chief complain of the patient most, with weighted mean of 4. 76 with verbal interpretation of “always”. In assessing for objective data, the respondents preferred assessing the patient from head-to-toe most with weighted mean of 4. 68, interpreted as “always”. In urinating an analysis of the problem, the respondents preferred to write using only AND approved nursing diagnosis most with a weighted mean of 4. 44 with verbal interpretation of “often”.

In formulating plan of care, the respondents preferred to ensure that the plan is realistic for the client’s capabilities, and limitation if it is indicated, most having a weighted mean of 4. 78 interpreted as “always”. University of Perpetual Help System -Content Stop Nine, Banana, Laguna In formulating interventions, the respondents preferred to include the client’s response to intervention after every implementation and to include the time when he interventions was done most, both interpreted as “often” with a weighted mean of 4. 49.

In formulating the evaluation, the respondents preferred writing the results or changes caused by nursing actions done and that if goals are unmet or partially met, to include reassessment of nursing action, both with verbal interpretation of “always” with a weighted mean of 4. 63. There was a significant difference in the documentation preference of Level Ill Clinical Instructors when grouped according to profile variable. The objective data between the age group below 30 and the age above 40 was found with a weighted mean of 4. 65, above the critical value of 3. 4. The plan of care between the male and the female group was discovered with a computed t-value of -2. 79. Between the group who graduated from Bachelor of Science in Nursing program of the year 2000 and below and those that graduated after 2000, with regards to their preferences on objective data, a computed t-value of 2. 24 was calculated, more than the 2. 02 critical value. The group who had a teaching experience of more than 5 years, with regards to their preferences in formulating the analysis of the problem. A computed t-value of 2. 1 was calculated, above the 2. 2 critical values. Conclusions Majority of the Level Ill – Clinical Instructors were aged 30-40, female, graduated from Bachelor of Science in Nursing Program on the year 2000 and below, and had a clinical and teaching experience of 5 years and less, both. Complain of the patient always. For objective data, the respondents always preferred assessing the patient from head to toe. For analysis of the problem, the respondents preferred to write only North American Nursing Diagnosis Association approved nursing diagnosis.

In plan of care, the respondents preferred to ensure that the plan is realistic for linnet’s capabilities and limitation if it is indicated, most. In formulating interventions, the respondents preferred to include client’s response to intervention after every implementation and to include the time when the intervention was done, most. In formulating evaluation, the respondents preferred writing the results or changes caused by nursing actions done, and that if goals are unmet or partially met, to include reassessment of nursing action most.

There is a significant difference between the documentation preferences of the clinical instructors. The documentation preference of each clinical instructor varies from one another. This implies that different clinical instructors have different points of view regarding documentations thus they also vary in teaching how to formulate documentation to students. Recommendations After careful deliberation of the results of the study, the researchers developed the following recommendations: 1 . The researchers recommend to the institution to reconsider their hiring preferences. A more experienced staff in both the clinical and teaching practice is recommended. 2. ) The researchers recommend to the students to utilize the preferences determined in this study as a guide to help them hone their skills in documentation. . ) The researchers recommend that the University of Perpetual Help Banana, College of Nursing to conduct educational programs and improve a focus on documentation, not the only for the students but for the faculty as well.

It is recommended to reinforce their skills and knowledge in documenting and create uniformity in the methods of documentation being utilized. Overall, the researchers strongly recommends to develop a standardized method of documentation to be implemented and practiced by the faculty and the students to exemplify the competence, excellence, quality of nursing care and high standard of education rendered by the said institution. 4. ) To future researchers, the researchers recommend to conduct further studies regarding documentation.

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