Implementation of Psychosocial Nursing Care Documentation For Pneumonia Patients: A Secondary Data Analysis in an Indonesian Hospital

Introduction: Nursing documentation is an important aspect of nursing practice so that should be assessed comprehensively. The objective of the study was to analyze the causing factor of nursing care documentation at Rumah Sakit Jiwa Menur Surabaya through balanced scorecard.Methods: This research was an analytical descriptive conducted out on January 2010 at Rumah Sakit Jiwa Menur Surabaya that measured nursing care documentation through four perspectives of balanced scorecard by distributing quisioner to 55 nurses and 69 customers (patient families) using inclusion criteria, and holding personal interview to 3 structural offi cial, 2 functional official, and 6 ward supervisors. Data of nurse education, percentage of trained nurse was gained by checklist. Data were analyzed using content analysis to fi nd the causing factor of nursing documentation within balanced scorecard.Result: The result showed that financial, internal business processes, and learning and growth perspectives had causal relationship with nursing care documentation at Rumah Sakit Jiwa Menur Surabaya, but customer perspective didn’t have direct causal relationship with it.Conclusion: It can be concluded that impractical nursing documentation form especially in dimension of time on assessment, implementation, and evaluation, and comprehension on assessment, absence of physical nursing standards, limited knowledge on nursing documentation evoked by absence of inhouse training about nursing documentation, ineffective supervision and audit were factors which affecting nursing documentation at Rumah Sakit Jiwa Menur Surabaya. The researcher recommended that the hospital manager should modificate the nursing documentation form using NIC & NOC of NANDA and computerized system, compose physical nursing standards, carry out advanced nursing education and inhouse training about nursing care documentation, improve supervision program, and nursing documentation audit.

Nursing documentation must be carried out at each stage of nursing care, so that it can be a means of nurse communication at work. Nursing documentation is a manifestation of nurses' accountability if nursing care services are disputed in the legal sphere. The phenomena, there are still many nurses who have not implemented nursing care documentation properly and correctly. The study was a correlational design with a population of all nurses in the inpatient unit of Bantur Public Centre Health, with a purposive sampling technique and a large sample of 14 people. Data collection using questionnaire instruments. The results showed that the majority of respondents (50%) applied sufficient nursing care documentation, the majority of respondents (58%) had sufficient knowledge. From the results of the Spearman statistical test, it is known, rho count = 0.923 and p value = 0, there is a correlation between the level of nurse knowledge about the standard of nursing care and the application of nursing care documentation. implementing of nursing documentation properly and correctly, it is necessary to have good knowledge about Nursing Care Standards. The better the knowledge about the standard of nursing care, the better the nursing care documentation that is applied.

Background : Nursing documentation is an important aspect of nurse profesionalism. Therefore each nurses should write down their activity properly according their role. However, to keep nurse documenting their prefossional behavior have been challanging according to studies. Objective: This study aims to portray how nurses perceived behavior control toward nursing documentation in hospital. Method: an observational study was conducted to investigate perceived behavior control among nurses working in ward setting. A total sampling technique was applied to recruite 47 nurses work in pediatric ward. Univariate analysis was utilized. Results: Most respondents were female, age 37.9 (7.5) years old on average, with undergraduate in nursing education background. Currently nurses were qualified for the first level of clinical nurse’s career path (PK 1), and working as associate nurses. The average score of nurses’ perceived control behavior over nursing care documentation was 68.59 (5.13). Conclusion: Nurses perceived behaviors control over nursing care documentation were slighty over the mediocre values, Nurses tend to have positive perception on their control over documenting nursing care.

Outpatient units have high activity and interaction, which increases the risk of neglecting full documentation of nursing care. This study aims to analyze factors contributing to the lack of optimal documentation of nursing care in an outpatient unit. This study employed a fish bone analysis approach to identify the root of problems of documenting nursing care in an outpatient unit. This research was conducted in an outpatient unit of the Children's and Mother's Hospital in Jakarta. The data collection techniques of this study were questionnaires, observations, and interviews with the head of the room, Clinical Instructors, implementing nurses, Case Managers, and Nursing Fields. The analysis reveals several results. Nurses, clinical instructors, activities in high work environments, as well as policies and tools for assessment and supervision are inadequate. The absence of effective systems and mechanisms for supervising nursing care documentation and manual documentation systems contributes to the lack of optimal documentation of nursing care in the outpatient unit. Documentation of nursing care extremely depends on the workforce, work climate, sets of policies, systems, and facilities. This study recommends programs and supervision activities for outpatient nursing care documentation performed by the Nursing Division, head of rooms, and Clinical Instructors, arranges supervision tools, arranges patients’ effective and efficient assessment documentation according to accreditation, policy re-socialization and documentation techniques, as well as energy management and implementation time documentation of nursing care in an outpatient unit.
 Keywords: clinical instructors, an outpatient unit, nursing care, nursing documentation, supervision nursing care documentation.

Purpose: Good health is a key Sustainable Development Goal, and quality nursing care documentation plays a vital role in achieving this goal by enhancing patient safety, care continuity, and accountability. Despite its importance, studies consistently show persistent gaps in nursing documentation that can compromise care outcomes and patient trust. This study describes efforts towards enhancing quality of nursing care documentation in County Referral Hospitals in Kenya. Methodology: Using a mixed-methods design, the research combined baseline audits of 158 patient files with surveys from 88 nurses and interviews with five nurse managers. An intervention phase followed, where a Continuous Professional Development (CPD) module was implemented in Nyeri County Referral Hospital. This training used a systems thinking approach to highlight how people, processes, and resources interact to affect documentation practices. Findings: Post-intervention, 62 patient files were audited, showing marked improvements: 93.5% of files contained patient details on every sheet (up from 44.4%), detailed assessments increased to 51.6%, and documentation of interventions, patient responses, and shift instructions all rose above 80%. Overall, there was improvement from 22% to 81.2% good nursing care documentation. Despite these gains, gaps remain, especially in timeliness and workload-related barriers. Unique Contribution to Theory, Practice and Policy: This study makes a unique contribution by demonstrating the effectiveness of a systems thinking approach in improving nursing documentation within resource-constrained settings. The study recommends conducting routine refresher training, and addressing staffing shortages to allow nurses adequate time for thorough, timely records. High-quality documentation supports critical thinking, legal protection, interprofessional collaboration, and patient-centered care. Sustaining these improvements demands committed leadership and continuous mentorship. This research highlights that targeted interventions, guided by systems thinking, can significantly enhance nursing documentation quality, ultimately contributing to safer, more effective healthcare delivery in Kenyan County Referral Hospitals and beyond.

BackgroundNursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, its practice and associated factors among Ethiopian nurses are not well investigated.ObjectiveTo assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia.MethodsAn institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses’ documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study.ResultsIn this study, 372 nurses participated, and 30.4% (95% confidence interval [CI]: 26%–35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio [AOR] = 4.16, 95% CI: [2.36–7.33]), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: [1.85–6.36]), adequacy of documenting sheets (AOR = 2.02, 95% CI: [1.14–3.59]), adequacy of time (AOR = 3.85, 95% CI: [2.11–7.05]), nurse-to-patient ratio (AOR = 2.78, 95% CI: [1.13–6.84]), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: [1.69–7.52]) were significantly associated with proper nursing care documentation practices.ConclusionNursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses’ knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.

Introduction: Nursing documentation should meet specific and comprehensive standards to achieve its goals, including effective communication, education, research, monitoring, and evaluation within the healthcare system. It should also ensure the collection of essential patient information based on established principles. This study investigated the factors that influence nursing documentation practices at the Federal Medical Centre in Apir, Benue State, Nigeria. The lack of national and local guidelines on nursing documentation has resulted in substandard practices among Nigerian nurses. Methods: The study employed an analytical cross-sectional design. There were 102 participants with a 99.7% response rate. Results: The practice of nursing care documentation was found to be inadequate. The practice of nursing care documentation was significantly linked to not having enough documentation sheets (AOR = 3.271, 95% CI = 1.125–23.704), not having enough time (AOR = 2.205, 95% CI=1.101–3.413), and not meeting the operational standard of nursing documentation (AOR = 2.015, 95% CI = 1.205–3.70). The results also highlight that while nurses recognise the importance of accurate documentation, several barriers, such as workload, inadequate training, and a lack of resources, hinder effective practice. Finally, more than half of nurses did not document their nursing care. Conclusion: The study concludes that addressing these barriers through targeted interventions could significantly improve documentation quality, thereby enhancing patient care outcomes. Agencies employing nurses must ensure to train them for proper nursing care documentation to improve knowledge and foster awareness among healthcare workers about accurate and thorough documentation practices. This will enable nursing directors and chief executive officers to access adequate documenting supplies, in addition to employing more competent and qualified nurses.

Nurses are responsible for continuous patient care. The proof of care activities is through documentation. Several studies have shown serious shortcomings in nursing care documentation. This study sought to determine the institutional factors that affect the quality of nursing care documentation. It was a descriptive survey, carried out in three County Referral Hospitals; Isiolo, Nyeri and Nyandarua in Kenya. The target population was nurse managers, and nurses in the selected hospitals, and patient case files in the medical surgical units of the sampled hospitals. Multistage technique was used to sample 88 nurses, 6 nurse managers, and 158 patient case files. Data was collected using a questionnaire and key informant guide. Themes and content analysis were used for qualitative data, while quantitative data were analyzed using regression analysis with SPSS (version 26.0). Findings were presented using frequency tables and charts. The results revealed only one-third (35.4%) of nursing care documentation practices were done well. Factors identified to influence nursing care documentation include existence of standard operating procedures on nursing care documentation, a high patient load per shift, and institutional culture on nursing documentation. Regression analysis demonstrated a positive relationship between the institutional factors, presence of SoPs, and institutional culture, with bivariate logistic regression scores of 1.335, 1.133, and 1.026 respectively. This association was not statistically significant, pointing to existence of confounding factors. This implies that improvement efforts must be made to identify and address other key process determinants. The study concludes that improvement of nursing care documentation practice requires identification and address of the multiple factors that affect the nursing practice. Health facility management is recommended to ensure that nurses have access to nursing documentation practices SOPs; to organize CPD sessions on nursing documentation; to build a positive culture on nursing documentation practices; and to adhere to the recommended nurse-patient ratios.

Nursing documentation is a critical element in ensuring patient safety, continuity of care, and professional accountability. However, the practice of documentation often encounters multiple challenges, including insufficient training, high workloads, limited resources, and the lack of clear operational guidelines. These barriers can impact the quality of care and patient safety, necessitating an in-depth exploration to understand and address them effectively. This scoping review aims to identify and analyze the factors hindering nursing care documentation, focusing on technical, individual, organizational, and contextual barriers across various healthcare settings. This review includes studies involving nurses and the factors affecting nursing care documentation. The concepts reviewed include barriers to documentation, such as individual, technical, organizational, and contextual obstacles. The context encompasses various healthcare settings, including hospitals, clinics, and community healthcare services across different countries. A comprehensive literature search was conducted using databases such as PubMed, ScienceDirect, Google Scholar, and ProQuest. Articles published between January 2020 and December 2024 were assessed using the JBI and MMAT critical appraisal tools. The selection process, based on PRISMA guidelines, identified 15 eligible articles for analysis. Key barriers to nursing documentation include inadequate training, low technological literacy, high workloads, infrastructure limitations, low motivation, and the absence of consistent documentation guidelines. These barriers affect the quality and accuracy of documentation, with implications for patient safety and service efficiency. Additionally, the findings highlight the need for improved supervision, auditing, and investments in documentation technology. Barriers to nursing care documentation require holistic interventions, including continuous training, technological infrastructure enhancement, and the implementation of clear operational guidelines. Further research is needed to explore effective solutions and their applications in diverse contexts.

Background: Nursing documentation is essential for quality of care, which facilitates continuity and individuality of care. Aim of the study: The study was aimed at assessing nurses' knowledge and auditing their practices regarding nursing care documentation. Setting: It was carried out in the medical and surgical units of Mansoura University Hospital. Design: using an analytic cross-sectional design. Subjects: Consisted o f 100 staff nurses and 557 nursing care charts. Tools and procedure: were a self-administered questionnaire and an audit sheet. The fieldwork lasted from April to July 2015. Results: The study revealed that nurses’ age ranged between 20 and 60 years, 77.0% having nursing diploma. 38% of the nurses had satisfactory knowledge about documentation. 18% of the nurses agreed upon the barriers hindering the quality of nursing documentation. Conclusion: the nurses in the study setting have inadequate knowledge about documentation, and minorities of them agree about the barriers hindering quality of documentation. Nurses’ audited practice is low. Recommendations: staff development activities are urgently recommended to improve nurses' knowledge and practice.

Nursing documentation is a description of the actions given by nurses to patients in nursing care. This documentation consists of assessment, diagnosis, outcome, intervention, implementation, and evaluation. Nursing documentation should be evaluated in relation to its application in providing nursing care. There is still diversity in formulating nursing diagnoses due to the variety of nursing education, knowledge of nurses, and even differences in the reference standards used. Nurses at Kaliwates General Hospital Jember have different backgrounds from different educational institutions. Training is needed in providing nursing care, especially in the formulation of nursing diagnoses. The purpose of this service is to increase knowledge and skills as well as to apply the SDKI, SLKI, and SIKI books in the preparation of nursing documentation. This service method is by collecting information related to the knowledge and skills of nurses about the application of the SDKI, SLKI, and SIKI; training by providing materials; mentoring; and evaluating the application of this book in the nursing care documentation process.

Introduction: Nursing documentation is evidence of nurses' recording and reporting in providing accurate and complete written health services. Documenting nursing care is quite important. However, there are still many incomplete nursing care documentations written by nurses. The factor that encourages nurses to carry out nursing documentation is the nurse's motivation and supported by rewards from the hospital as appreciation for the nurse's performance. Objective: The purpose of this study was determine the Correlation between Nurse Motivation and the Quality of Nursing Care Documentation. Method: This research is a quantitative study with a correlation study and a cross sectional design. The sampling technique used was random sampling with 66 respondents at RSUD Dr. R. Soedjati Somodiarjo Purwodadi. The data were analyzed by using the chi-square statistical test (X2) and a correlation strength test was carried out using Spearman's (r). Results: Based on the chi-square statistical test (X2), the p value is 0.000. As the results show <0.05, it means that Ha is accepted and Ho is rejected. Then a correlation strength test carried out by using Spearman’s (r) reveals a correlation coefficient or r = 0.086, indicating that there is a strong positive correlation between nurses’ motivation and the quality of nursing care process documentation at RSUD Dr. R. Soedjati Somodiarjo Purwodadi. Conclusion: The results of the study indicate that there is a positive correlation between nurses’ motivation and the quality of the nursing care process documentation at RSUD Dr. R. Soedjati Somodiarjo Purwodadi.

Introduction: Nurses' lack of understanding and non-compliance in nursing documentation resulted in low quality of documentation and nursing services. One of factors which affects nursing documentation is self-efficacy. The purpose of this study was to know the correlation of self-efficacy and the compliance of nurses in the nursing documentation. Methods: This research used cross-sectional design with the descriptive documentation approach. The sample of the study was 23 nurses in a hospital recruiting with a nonprobability technique type i.e. total sampling. The inclusion criteria in this study were nurses who were willing to be respondents and had at least a diploma in nursing education. The instrument used was a self-efficacy questionnaire and the nursing care documentation compliance observation sheet. Data analysis used Rank Spearman test with the meaning level 0.05. Results: Most of nurses had high self-efficacy (69.9%) and majority nurse obey in nursing care documentation (73.9%). The statistic test showed p value = 0.000 < (0.05) with r = 0.898. Conclusion: This result confirmed that there is a relation between self-efficacy and the compliance of nurses in nursing documentation at hospital.

BackgroundNursing documentation is an essential component of nursing practice and has the potential to improve patient care outcomes. Poor documentation of nursing care activities among nurses has been shown to have negative impacts on healthcare quality.ObjectiveTo assess the nursing documentation practice and its associated factors among nurses working in the North Shewa Zone public hospitals, Ethiopia.MethodAn institution-based cross-sectional study was conducted at the North Shewa Zone public hospitals. A simple random sampling technique was used to select 421 nurses. A pretested, structured, self-administered questionnaire was used to gather the data. Data were entered into Epi Data version 3.1, and SPSS version 25 was used for further analysis. Binary logistic regressions were performed to identify the independent predictors of nursing documentation practice. Adjusted odds ratio was calculated and a p-value less than 0.05 with 95% confidence interval (CI) was considered as statistically significant.ResultA total of 421 respondents took part, giving the survey a 100% response rate. The overall good practice of nursing care documentation was 51.1%, 95% CI (46.6, 55.8). In addition, 43.2%, 95% CI (38.5, 48.0) and 35.6%, 95% CI (30.9, 40.1), of nurses had good knowledge of and favorable attitudes toward nursing care documentation. Availability of operational standards for nursing documentation [adjusted odds ratio (AOR) = 1.76; 95% CI: 1.18, 2.64], availability of documenting sheets (AOR = 1.51; 95% CI: 1.01, 2.29), and a monitoring system (AOR = 1.61; 95% CI: 1.07, 2.41) were significantly associated with nursing care documentation practice.ConclusionNearly half of nursing care was not documented. The practice of nursing care documentation was significantly influenced by the availability of operational standards, documenting sheets, and monitoring systems. To improve the documentation practice, a continuous monitoring system and access to operational standards and documenting sheets are needed.

Nursing documentation is a means of communication between medical personnel aimed at restoring patient health. Documentation is nursing work that can facilitate nursing management, improve continuity of care, coordinate care, and evaluate patient interventions. DThe completeness and suitability of nursing care documentation in accordance with the 3S nursing care process standards (SDKI, SLIKI, SIKI) in several hospitals is still low. Implementing case reflection discussions can help improve a nurse's ability to carry out good and effective planning in improving the quality of nursing. This research is to determine the influence of case reflection discussions (drk) on improving nursing care documentation according to 3s standards (SDKI, SLKI, SIKI). This article was written using a literature study method which was analyzed from several journals related to the topic taken, journals were searched through Proquest, Pubmed, Google Scholar, Garuda, Sinta, which were then selected according to the topic, literature searches were carried out within the publication period journal from 2018 to 2024. The results of the discussion of the analysis of 20 literature reviews with hypothesis testing for each journal show that there is an influence of DRK on the quality of nursing care. DRK has the benefits of increasing knowledge, solving service problems, increasing awareness of quality practices and critical thinking. Nurses' knowledge influences the documentation of nursing care according to 3S standards (SDKI, SLKI, SIKI). One way to increase nurses' knowledge is with Case Reflection Discussions (DRK).