Nursing care activities based on documentation.

Area of Science:

• Nursing Care Quality
• Healthcare Documentation Standards
• Patient Safety Initiatives

Background:

• Nurses perform critical activities from patient admission to discharge, requiring accurate documentation as evidence.
• This study investigated nursing activities based on completed documentation to assess care delivery.
• Proper documentation is essential for authenticating nursing interventions and evaluating patient outcomes.

Purpose of the Study:

• To identify and evaluate the extent of nursing activities documented in patient records.
• To compare documented nursing activities against established standards of care.
• To highlight the importance of accurate nursing documentation for effective patient care.

Main Methods:

• A quantitative, retrospective study analyzed 240 medical records from Dr. Kariadi Hospital (July-September 2016).
• Records were randomly selected for common medical/surgical diseases with hospital stays exceeding 3 days.
• Data from patient progress notes were collected using an observation form and analyzed with univariate statistics.

Main Results:

• Documented nursing activities were found to be insufficient across various categories.
• Specific documented activities included assessment of decubitus risk (20.8%), nursing diagnosis formulation (20.8%), and collaboration in drug administration (60.8%).
• Other documented areas showed low compliance, such as biological status assessment (0.4%) and resume nursing activities (0.8%).

Conclusions:

• Nursing activities are vital for patient problem-solving and require critical thinking in documentation.
• Inaccurate or unclear nursing documents impede inter-professional communication and care evaluation.
• Continuous oversight and evaluation of nursing activities and documentation by nurse managers are essential for quality improvement.