Nurses’ Experiences During Assessment and Documentation of Mental Healthcare Users During Admission at Selected Hospitals of Vhembe District, Limpopo Province, South Africa ^†

Background: Nursing assessment and documentation for mental health care users (MHCUs) are essential components of mental health care, vital for ensuring patient safety, effective treatment planning, and high-quality service delivery. However, inadequate or incomplete documentation can compromise the quality of care provided to MHCUs. Objectives: This study explored nurses’ experiences during the assessment and documentation of MHCUs upon admission at selected hospitals in the Vhembe District, Limpopo Province, South Africa. Specific objectives were to describe these experiences and to propose strategies for improving nursing assessment and documentation practices in these settings. Methods: A qualitative, explorative, descriptive, and contextual research design was used. Non-probability purposive sampling selected nurses from the targeted hospitals. Data were gathered through semistructured, one-on-one interviews guided by an interview schedule, continuing until saturation was reached at the sixteenth participant. Data analysis followed Tesch’s open coding method. Ethical principles and measures to ensure trustworthiness were maintained throughout the study. Results: Six key themes emerged: nurses’ experiences of assessing MHCUs; experiences of teamwork during assessments; experiences related to documentation; combined experiences of assessment and documentation; challenges faced during assessment; and recommendations for improving practices. Conclusion: Findings revealed the complexity of conducting both physical and psychosocial assessments, the importance of family involvement, the need for clinical expertise, and the benefits of intra- and interprofessional teamwork. Challenges included resource limitations, staff shortages, and managing aggressive patients. Despite these obstacles, nurses recognized the critical role of thorough documentation for legal protection, care planning, and accountability. Implementing the recommended strategies could enhance MHCU assessment and improve overall quality of care.