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.