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

Abstract

Completeness of documentation as a legal aspect and proof a nursing activity. Nothing documentation means nothing activity. This research aims to identify the legal point and integrity of nursing documentation after applying electronic nursing documentation. 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 to Compare the legal aspect and completeness of data conducted before and after implementation of the new system. The study showed improvement of the legal elements increased by 45.7% (4,37 to 8,00) and completeness documentation by 10.39% (43,00 to 49,03) after use of the system. Nursing Electronic Documentation improved legal aspect, completeness nursing and enhance the quality of nursing care. Electronic nursing documentation can be done to support and increase the quality of nursing.