Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study

Abstract

Background: Completeness of documentation as a legal aspect and proof a nursing activity. Nothing documentation means nothing activity.Objective: The Purpose of research to identify the legal aspect and completeness of nursing documentation after applying electronic nursing documentation.
 Methods: Report study approach and using pre and post-test with the control group. Thirty Four documentation collected using consecutive sampling on one-week observation before and after using electronic nursing information. The research compared the legal aspect and completeness of data conducted before and after the implementation of the new system.Results: The study showed improvement of the legal aspects increased by 50% (4,40 to 8,00) and completeness documentation by 10.39% (43,00 to 49,00) after used of a system. 
 Conclusion: Nursing Electronic Documentation improved legal aspect, completeness nursing and enhance the quality of nursing care.
 Recommendation: Electronic nursing documentation can be done to support and increase the quality of nursing.

The Role of Nurse Motivation, Competence And Workload for Increasing Completeness of Nursing Process Documentation At Class B Private Hospital In Jakarta

“…This instrument has been tested for validity and reliability with a Cronbach alpha value of 0.94 Competency Questionnaire. This competency questionnaire is used to measure the competency level of nurses adopted by Spencer et al (7). This questionnaire consists of 4 dimensions, including 1) knowledge, 2) skills, 3) attitudes, and 4) clinical nurse competence.…”