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Indian Journal of Forensic Medicine & Toxicology
Year : 2019, Volume : 13, Issue : 4
First page : ( 1591) Last page : ( 1595)
Print ISSN : 0973-9122. Online ISSN : 0973-9130.
Article DOI : 10.5958/0973-9130.2019.00532.2

The Completeness of Nursing Care Documentation in Fakfak Hospital

Manoppo Inggerid Agnes1,*, Banna Triani1

1Papua Health Science Institute

*Corresponding author: Inggerid Agnes Manoppo, (inggeritmanoppo@stikessorong.ac.id) Address: Campus of Papua Health Science Institute, Sorong, Indonesia

Online published on 27 November, 2019.

Abstract

Completeness of nursing care documentation is part of service quality in a hospital and as a legality from nursing practice. Fakfak Hospital in implementing nursing care on average has not been complete. However, there is nursing care documentation sheet but it has not been filled completely. Moreover, this study aimed at investigating the factors that influenced the completeness of nursing care documentation in Fakfak Hospital. This study was a quantitative study by utilizing cross sectional study design. Subjects of this study was 70 nurses in six inpatient rooms, selected by purposive sampling. The crosstab stated that there was a significant influence between assessment and documentation. Besides, there was a significant influence between diagnosis and documentation. There was a significant influence between action plan and documentation. There was a significant influence between implementation of action plan and documentation. For the last, there was a significant influence between evaluation and documentation. All in all, in this study, there was a significant influence among assessment, diagnosis, action plan, implementation of action plan, and evaluation against the completeness of nursing care documentation. Therefore, suggestion in this research was it needed a training that was given by a superior in filling nursing care in inpatient room, and also completing the format of assessment, diagnosis, action plan, implementation of action plan, and evaluation based on the standard of Health Department.

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Keywords

Assessment, Diagnosis, Action plan, Implementation, Evaluation, Documentation.

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