Abstract

Introduction: Implementation of the nursing care process is still a problem in nursing services. The problem found in the nursing process is the accuracy of nurses in applying the nursing care process. The aim of this study to analyze the accuracy of the implementation of the nursing care process.Methods: This study was as a descriptive analytics design with 100 respondents. Samples were selected using cluster sampling. Data were collected using a questionnaire that has been tested for validity and reliability. The variables included assessment, nursing diagnosis, nursing plan, nursing implementation, evaluation, and nursing documentation. Data were analyzed in a descriptive form consisting of good, sufficient and fewer categories. The standard for implementing the accuracy of the nursing process is 100%.Results: The result showed the accuracy of implementation nursing care, namely 64% assessments are sufficient, 69% of nursing diagnosis is sufficient, 59% of nursing plans are sufficient, 66% of nursing implementation is sufficient (), along with 60% of nursing care evaluation and 62% of nursing care documentation.Conclusion: The accuracy of the nursing care process describes the quality and patient safety and is useful for patients, nurses, and the health team. Further studies must be conducted to analyze factors related to accuracy of the implementation of the nursing care process.

Highlights

  • Implementation of the nursing care process is still a problem in nursing services

  • The result showed the accuracy of implementation nursing care, namely 64% assessments are sufficient, 69% of nursing diagnosis is sufficient, 59% of nursing plans are sufficient, 66% of nursing implementation is sufficient (), along with 60% of nursing care evaluation and 62% of nursing care documentation

  • Further studies must be conducted to analyze factors related to accuracy of the implementation of the nursing care process

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Summary

Introduction

Implementation of the nursing care process is still a problem in nursing services. The problem found in the nursing process is the accuracy of nurses in applying the nursing care process. The aim of this study to analyze the accuracy of the implementation of the nursing care process. Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse (Tasew, Mariye and Teklay, 2019). Documentation is an authentic record in the application of management of professional nursing care. Nursing documentation is evidence of recording and reporting of nurses is useful for the benefit of clients, nurses and healthcare team in providing health services with accurate and complete data written as a

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