Nursing Documentation in Accredited Hospital

Abstract

Nursing documentation is assessed in hospital accreditation because it includes the actions taken and the quality of provided care. Hospital accreditation undergoes three phases consist of preparation, implementation, and post-accreditation. In the post-accreditation phase, there is reduced compliance of workers and nurses. This study determines the quality of nursing documentation at the fully accredited hospital by using descriptive and quantitative research with a retrospective approach. A simple random sampling method is used to attain 292 documents. Data are collected using the Evaluation of Nursing Care Instrument by the Ministry of Health Republic of Indonesia. Results show that nursing documentation has poor quality with an average achievement of 80.81%. In terms of components, the implementation is the most complete whereas the intervention and nursing care parts are the least filled out. Most of the factual indicators have good quality but other records have poor completion or compliance. Observation indicators for documentation quality need review to determine the factors that influence the decline in quality. Hospitals need to review and improve nursing documentation to prevent quality deterioration in the post-accreditation survey. Using information technology for documentation can help nurses because the standardized language and linked systems facilitate documentation of the entire care process, and thus enhance its completeness.Abstrak
 Dokumentasi Asuhan Keperawatan pada Rumah Sakit Terakreditasi. Dokumentasi asuhan keperawatan dinilai dalam akreditasi rumah sakit karena berisi seluruh tindakan keperawatan dan mencerminkan kualitas asuhan keperawatan yang diberikan. Akreditasi rumah sakit terdiri atas tiga fase yaitu fase persiapan, implementasi, dan pasca akreditasi. Pada tahap pasca akreditasi, biasanya terjadi penurunan kualitas pelayanan. Penelitian ini menelusuri kualitas dokumentasi asuhan keperawatan di Rumah Sakit X yang terakreditasi paripurna dengan menggunakan desain deskriptif kuantitatif melalui pendekatan retrospektif. Sebanyak 292 sampel dokumen diperoleh dengan teknik simple random sampling. Data dikumpulkan dengan menggunakan Instrumen Evaluasi Asuhan Keperawatan oleh Departemen Kesehatan Republik Indonesia. Hasil penelitian menunjukkan kualitas dokumentasi keperawatan tidak baik, dengan pencapaian rata-rata 80,81%. Komponen implementasi merupakan yang paling banyak terisi, sedangkan intervensi dan catatan asuhan keperawatan paling sedikit terisi. Sebagian besar indikator faktual memiliki kualitas yang baik, tetapi catatan lain memiliki kelengkapan yang buruk. Indikator observasi kualitas dokumentasi perlu dikaji ulang untuk mengetahui faktor-faktor yang memengaruhi penurunan kualitas dokumentasi keperawatan. Rumah sakit perlu meninjau dan meningkatkan dokumentasi keperawatan untuk mencegah penurunan kualitas dalam survei pasca akreditasi. Penggunaan teknologi informasi untuk dokumentasi dapat membantu perawat karena adanya standarisasi bahasa dan sistem yang saling terkait memfasilitasi dokumentasi seluruh proses perawatan, dan dengan demikian meningkatkan kelengkapannya.
 Kata Kunci: akreditasi, asuhan keperawatan, dokumentasi keperawatan, rumah sakit

An integrative review of Indonesia’s quality of care

“…The study overview can be seen in Table 1. [22] 2006b Qn Central registration of nurses [23] 2007 Qn Low QNC is related to negative patient satisfaction [24] 2007 Ql Nurses' empowerment [25] 2007 Qn Burnout has a negative impact to QNC [26] 2009 Qn Low QNC is related to low patient satisfaction [27] 2010 Qn QNC has a relationship with patient satisfaction [28] 2010 Qn Nursing care delivery models predicted quality of care [29] 2012 Qn Training will impact QNC [30] 2012 Qn Nursing perception related to documentation [31] 2012 Qn Nursing care delivery models will impact QNC and increase patient satisfaction [32] 2013 Qn Supervision will increase QNC [33] 2013 Qn Workload has a significant relationship with QNC [34] 2013 Qn i) Period of employment; ii) Training; and iii) Workload [35] 2013 Qn Supervision will increase QNC [36] 2015 Qn QNC impacted patient satisfaction [37] 2015 SR i) Healthcare delivery risk infection; ii) Medication errors; iii) Quality care delivery; and iv) The quality of healthcare overall. [38] 2016 Qn Nurse-physician relationship has a relationship with QNC [39] 2016 Qn Critical thinking influences nurse work [40] 2017 Qn Discharge planning influences QNC [41] 2017 Qn Standard will improve QNC [42] 2017 Qn Nursing rounds will improve QNC [43] 2017 Qn i) Knowledge; ii) ability/skills; iii) education; and iv) gender have relationships with nursing action [44] 2018 Qn Job satisfaction will impact QNC [8] 2018 Qn Turnover impacted QNC [45] 2018 Qn QNC impacted patient satisfaction [46] 2018 Qn Training of Soft Skills Caring will increase competency, that would impact patient satisfaction [47] 2018 Ql Competence [48] 2018 LR It helps nurse work effectively and efficiently for increasing quality [49] 2019 Qn Significant relationship [50] 2019 Qn Insufficient nursing activities could not fulfill the patient needs <...…”

“…Job design refers to a job description that includes everything needed to complete the work as described by the position and responsibility. Job design factors were nursing care delivery [20], [31], [51], training needs [21], nurse competencies [46], nursing roles [21], nursing rounds [42] and nursing documentation [23], [29], [30], [40], [48]. In addition, the other important factors came from the nurses that were reported from four studies.…”

“…The next era indicated competency, training needs, work environment, nursing roles, central registration of nurses, burnout, and nurse satisfaction were needed to reconstruct in order to increase the quality of care [21], [22]. Nursing documentation, nursing care delivery models, workload, supervision, the inadequacy of patient evaluation, necessary supplies, and case management were the problems 2011-2015 [29], [31], [33], [37]. Finally, in the last five years, 2016-2020, the actual situation of nursing in Indonesia were common interest or nurse-physician relationships, nursing rounds, nursing documentation, nursing competency, knowledge, ability or skills, gender, training needs, critical thinking, caring behavior, nursing care delivery models, turnover, and managerial function [8], [38], [40], [42], [43], [46], [48], [51]- [54], [58].…”

Implementation of Discharge Planning for Hospitalized Children with Tonsillitis: A Case Study

“…Then an assessment is carried out that focuses on patient care during treatment and when the patient is at home, which is then diagnosed until evaluation involving the patient and family. All of the nursing processes must be documented (Purwandari et al, 2022).…”

Transformational leadership improves nursing documentation self-efficacy

“…These results are similar to a study by Purwandi et al, which found that Transformational leadership improves nursing documentation self-efficacy the quality of nursing documentation was poor, with an average achievement of 80.81%. 15 Poor quality in nursing documentation was influenced by nurses' self-efficacy.…”