Nursing care systems face significant challenges due to demographic changes, a workforce shortage, and rising demand for care services. Digital assistive technologies offer potential to address these challenges, but systematic and standardized nursing data are essential to evaluate both innovations and broader care processes. The Nursing Minimum Data Set (NMDS) provides a foundational framework for capturing structured information on nursing care, yet there is no international consensus on its core content, development, and practical use. This scoping review aims to map current international literature regarding (1) the core content elements of NMDS, (2) methodological approaches used in NMDS development, and (3) implementation and use of NMDS in different nursing settings. Following the JBI (Joanna Briggs Institute) methodology and Arksey and O'Malley framework, a systematic search was conducted on July 2, 2025, in the MEDLINE (via PubMed) and CINAHL (via EBSCO) databases using the term "nursing minimum data set." Inclusion was restricted to studies in English or German focusing on the content, development, or implementation of the NMDS. The research team reviewed studies in an independent and double-blinded fashion for eligibility based on predefined criteria, with discrepancies resolved by consensus. Eligible studies were narratively summarized, with extraction structured into categories based on the review's research questions. From 1908 initially identified articles, 26 (1.4%) studies met the inclusion criteria. Considerable heterogeneity was found in the structure and scope of the NMDS, with datasets comprising 16 to 145 items. Despite variation, 4 central domains consistently emerged: patient demographics, medical care information, nursing care elements, and institutional or organizational data. NMDS development typically followed a participatory, multistage approach involving literature analysis, stakeholder consensus building, and validation through pretesting and real-world application. Implementation and use of the NMDS serve multiple functions, including documenting nursing care processes, supporting workload measurement and resource planning, quality assurance, benchmarking, and demonstrating nursing's contribution to patient outcomes. However, successful implementation depends on technical, legal, organizational, and educational strategies. Core challenges include a lack of standardized terminology, inconsistent legal frameworks, and varying levels of staff training and acceptance. The NMDS provides a robust basis for standardized nursing documentation, quality assurance, and health system planning, but international variability and ongoing challenges in harmonization, integration, and acceptability persist. Advancing the NMDS requires collaborative efforts for interoperability, investment in digital infrastructure, and targeted education. Further research should focus on comparative effectiveness, cross-context validation, and strategies to reduce documentation burden while maximizing data utility.

The purpose of this study is to develop and integrate Automatic Speech Recognition (ASR) technology into electronic health record (EHR) for nursing documentation. This study was conducted at a hospital in Seoul, South Korea, and followed the constructive ehealth evaluation method (CeHEM) framework, encompassing 6 phases: research and planning, design, development, implementation, evaluation, and redesign. A multidisciplinary ASR Project task force team, composed of experts from diverse domains including nursing, ASR technology, and EHR systems, led the project. Version 1 of the Nursing ASR system underwent 2 pilot deployments. It was initially integrated into nursing notes and later expanded to the Kardex, which entails considerable nursing documentation. Following the pilots, feedback was gathered from clinical nurses through interviews and an online survey to identify ASR system issues and areas for improvement. Based on these findings, the task force team proposed targeted solutions that informed the development of Version 2. The updated system was redesigned to support a broader range of nursing tasks, offer more intuitive voice commands, and provide a mobile application version to enhance accessibility. This study highlights the importance of nurse-centered, iterative development and demonstrates how interdisciplinary collaboration can translate user feedback into system improvements. The findings provide practical insights for health care organizations adopting ASR technologies.

The high quality of nursing documentation is a prerequisite for the secondary use of data. Poor-quality data can lead to incorrect decision-making. This study aimed to describe the assessment of nursing documentation quality and the utilization of this assessment data in the knowledge-based management and development of daily nursing practices. Using a cross-sectional study design, an online survey of information systems for registered nurses in Finland was conducted in spring 2023. A total of 2970 nurses responded. Descriptive methods were used to characterize the frequency of the secondary use of nursing data. Across units, nursing documentation quality was not assessed in 51% of cases, results were not reviewed in 66% of units, and nursing data were not used for knowledge-based management in 58% of units. In private health care and social services, nursing documentation reviews occurred in 21% of units, and 24% reported using nursing data for knowledge-based management. In contrast, public hospitals demonstrated lower engagement, with only 17% of units reviewing nursing documentation and 13% utilizing nursing data for management purposes. The private sector led in the secondary use of nursing data compared with other sectors. Nursing managers consistently provided more positive responses than nurses across all aspects of secondary use of data. This difference may stem from the fact that nursing managers use secondary data for daily management.

Perianesthesia Nurses' Perspectives Managing Frailty: A Qualitative Study.

This study evaluated the effectiveness of virtual reality simulation in enhancing nursing students' competency in the nursing process. A multicenter randomized controlled trial was conducted at 3 nursing schools with 62 students randomly assigned to either an experimental group or a control group. The experimental group used the Oculus Quest 2 to engage in a 360-degree video-based simulation of a patient with pulmonary thromboembolism, while the control group reviewed the same scenario using text-based materials. Both groups collected objective and subjective patient data and completed nursing process documentation. Confidence in the nursing process and preparedness for practice were assessed through pretests and posttests. Learning satisfaction and engagement were measured postintervention. The quality of nursing process documentation was evaluated by an independent rater blinded to group assignment. The experimental group showed significantly higher scores in documentation quality and reported greater learning satisfaction than the control group. However, no significant differences were observed in engagement, confidence, or preparedness between the groups. These findings suggest that 360-degree video-based virtual reality simulations can effectively support nursing students' learning of the nursing process. To maximize learning outcomes, future research should incorporate more active learner participation, including verbal and physical task performance, along with structured debriefing and feedback.

Perioperative nursing documentation is crucial for patient safety and treatment efficacy. Nevertheless, traditional recording methods are often associated with high error rates and inefficiency. This study developed and evaluated an intelligent control system that integrates radio frequency identification (RFID) wristband scanning, personal digital assistant (PDA) mobile recording, blockchain signature authentication technology, and modules for real-time alerts, process monitoring, and quality control. The system's effectiveness was evaluated by comparing qualification rates and the time required for inspections. A pre-post comparative design was used, with 200 perioperative nursing records randomly selected from both pre-implementation and post-implementation periods for review. Quality control nurses assessed documentation compliance across 5 dimensions: completeness, accuracy, timeliness, standardization, and logical consistency, using a passing score of 90 points or higher. Results demonstrated a significant improvement in nursing documentation compliance following system implementation, accompanied by a marked reduction in quality control time (both metrics, P <.05). Nurse satisfaction scores averaged 96.73±1.96. These findings indicate that the system effectively enhances nursing documentation quality, reduces the time required for quality control, and has been well-received by nursing staff. Future research should investigate the system's long-term clinical impact, its interoperability with electronic health record systems, its cost-benefit profile, and its applicability across various surgical settings.

Objective: This study aimed to investigate how nurses' backgrounds, documentation skills, and experiences with documentation practices and information systems usage influence documentation hazards and to determine whether these hazards are linked to technology-induced errors (TIEs). Methods: An online survey was conducted to collect data from 3065 registered nurses working in Finnish hospitals and in acute, primary, and home care services regarding their experiences with electronic health records (EHRs) or client information systems (CIS). The data were analysed using linear and logistic multilevel models to identify patterns and correlations. Results: User interaction with EHR/CIS systems significantly influenced documentation hazards across different work environments. Perceived system-provided documentation support and documentation hazards were identified as contributors to TIEs. Conclusions: Improving system design and documentation support is a desirable goal, but it is not sufficient to mitigate documentation hazards and promote efficient practices. To achieve the best possible results, skilled users are needed to operate these systems.

Nursing rounding is conducted every two hours, which includes monitoring patient complaints, monitoring IV line complaints, positioning the patient comfortably, meeting personal needs, meeting elimination needs, and maintaining privacy. In-service conditions, nurses' compliance with nursing rounding documentation remains low. Compliance with nursing rounding documentation can be improved through nurse supervision. This study aims to analyze the relationship between supervision and compliance with nursing rounding documentation. This study used a correlational analytical approach with a cross-sectional method. A sample of 84 nurses was selected using purposive sampling from a population of 90 nurses. The instruments used included a nursing rounding documentation observation questionnaire, GROW-ME coaching, and a compliance observation sheet. Data analysis was performed using the Spearman Rho correlation test. Most nurses received good supervision (89%). Eighty percent of nurses demonstrated compliance with nursing rounding documentation. There was a significant relationship between supervision and nursing rounding documentation (p=0.000). Nurse supervision significantly increased compliance with nursing rounding documentation. It is recommended that institutions strengthen coaching, training, and motivation programs to improve the quality of documentation and overall nursing care.

Electronic health record support nurses' work in many ways; however, nursing documentation within the system has also been associated with burden and noncompliance with organizational and regulatory requirements. An increasing number of studies have analyzed nursing documentation burden and noncompliance, but no scoping review has been conducted that focuses on electronic health record-based strategies for improving nursing documentation. This scoping review aimed to identify electronic health record-based strategies for improving nursing documentation in hospital settings. The Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews guidelines were used, and databases MEDLINE, Web of Science, and CINAHL were searched on April 1, 2024. A total of 652 studies were retrieved, of which 25 were incoluded at the full-text level. Six documentation issues emerged across the studies, with 44% identifying documentation compliance as the main issue. Three electronic health record-based strategies, such as organizational change, end-user reminder system, and financial incentives, regulation, and policy, were identified. Six documentation improvement outcomes with findings were identified, with 52% of the studies' outcome demonstrating improved documentation compliance. This review identified electronic health record-based and supplemental strategies that concentrate on improving nursing documentation. More research is needed to identify how these strategies may affect other measures, such as patient care outcomes, accuracy and quality of nursing documentation, and costs associated with nursing time spent on documentation activities.

Introduction: The implementation of standardized nursing care documentation remains a challenge in many hospital units, especially in high-demand wards where workload and time constraints affect nurses’ compliance. The 4S model, comprising SDKI (Nursing Diagnosis Standard), SIKI (Nursing Intervention Standard), SLKI (Nursing Outcomes Standard), and SPO (Standard Operating Procedures), provides a structured approach to ensure consistency, accuracy, and accountability in nursing care. However, limited understanding and practical application among nurses often lead to variations in documentation quality. Objective: This community service aimed to enhance nurses’ understanding and competence in implementing the 4S model through structured training and direct supervision at BLUD Jayapura General Hospital. Method: The program was carried out by nursing lecturers and students from Universitas Strada Indonesia in collaboration with BLUD Jayapura General Hospital. The activities took place from October 10 to 12, 2025, involving 25 participants consisting of 2 head nurses and 23 staff nurses from the Women’s Surgery and Pulmonary Wards. The program included lectures, workshops, group discussions, and on-the-job training. Evaluation was conducted using pre- and post-tests to measure knowledge improvement, and data were analyzed using a paired sample t-test. Result: The average pre-test score was 62.00 ± 8.12, which increased to 86.00 ± 6.47 after the training (p = 0.000). Participants reported better comprehension of the interrelation between SDKI, SIKI, and SLKI, as well as improved ability to formulate nursing diagnoses, interventions, and outcomes. Most participants also expressed that the integrated documentation format simplified their workflow and supported nursing quality audits. Conclusion: The 4S-based nursing care training effectively improved nurses’ knowledge and practical skills in applying standardized nursing documentation. The program strengthened clinical accountability, enhanced documentation consistency, and supported quality improvement initiatives at BLUD Jayapura General Hospital. Future programs are recommended to expand this training model to other hospital units and integrate the 4S framework into electronic nursing documentation systems.

The development of information and communication technology has led to significant changes in the provision of nursing care. This study examines nurses' experiences with using Electronic Medical Records (EMRs) for nursing care documentation. This study aims to explore the experiences of nurses using EMR in documenting nursing care. This qualitative study uses a phenomenological approach involving 10 nurses, including the head of the room, team leader, and implementing nurses. Participants were selected using purposive sampling techniques, with the following criteria: nurses who perform nursing care documentation using an Electronic Medical Record (EMR), nurses working in inpatient, outpatient, emergency (IGD), and intensive care units, nurses with a work experience of at least 2 years, and nurses who are willing to participate. The study was conducted at a private hospital in Pekanbaru. Data were collected through interviews and analysed using thematic analysis, employing the Colaizzi method. Result: The analysis revealed three themes: the benefits of Electronic Medical Records (EMR) in nursing services, supporting factors for the implementation of EMR, and inhibiting factors for the implementation of EMR. Based on the study results, it can be concluded that nurses feel the effectiveness and efficiency of EMR in documenting. However, during its implementation, there are still obstacles that require attention from hospital management. Thus, providing health services becomes optimal and efficient for patients and health workers.

Nursing services play an essential role in improving the quality of healthcare, with nursing care documentation serving as a key indicator of nurses’ performance. However, documentation practices in many hospitals remain suboptimal and often fall below the required standards. This Community Service Program (PkM) aimed to improve the quality of nursing care documentation through training on the nursing process based on the 3S model (Indonesian Nursing Diagnosis Standards, Nursing Outcomes Standards, and Nursing Interventions Standards) at RSIA Annisa Pekanbaru. The training was conducted over one year using seminars and hands-on practice, involving 20 inpatient nurses and nursing students. Evaluation results showed an increase in participants’ knowledge from 90% (pre-test) to 100% (post-test) after receiving the training materials. Participants also demonstrated high enthusiasm in understanding the importance of applying the 3S model to enhance documentation quality. This program successfully improved nurses’ competencies and produced outputs such as a training module, a mass media publication, and a draft manuscript for submission to a nationally accredited journal. In conclusion, training on the nursing process using the 3S approach proved effective in improving the quality of nursing care documentation and supporting the professionalism of nurses in healthcare services

Background: Nursing informatics competencies are the skills and knowledge that nurses must master to effectively integrate digital technology into nursing practice. Digital nursing documentation simulation is an innovative learning program that utilizes digital technology to create nursing care documentation. This allows students to train in a safe environment that reflects real life clinical conditions, with a facilitator providing feedback. Purpose: To determine the effect of digital nursing documentation simulation on nursing informatics competency. Method: A quasi-experimental design with a pretest and posttest one-group design. The population was 22 undergraduate nursing students enrolled in the Faculty of Health Sciences, Jenderal Achmad Yani University, year level 4th, with a sample size of 22 participants. The digital nursing documentation simulation was administered in three stages: orientation to digital nursing documentation learning, completing nursing care documentation using a computer-based application program, and evaluation and feedback. Nursing informatics competency among nursing students was compared before and after the intervention using the Self-Assessment Informatics Competency Scale (SICS). Data were analyzed using the Wilcoxon test. Results: The average informatics competency before the intervention was 3.32, while the average informatics competency after the simulation was 3.59. There was a significant effect of digital nursing documentation simulation on nursing informatics competency (p value: 0.014). Conclusion: The application of digital nursing documentation simulation has a positive impact on Nursing Informatics Competency, especially in nursing students, in implementing nursing care.

BackgroundNon-traumatic chest pain requires rapid Emergency Department (ED) triage, yet adherence to ECG ≤10 min and early troponin targets is inconsistent, standard nursing frameworks seldom prompt patient-needs that affect timeliness and documentation. The aim of this study is to determine whether implementing a patient-needs-enhanced Emergency Nursing Assessment Framework (ENAF), compared with usual care, increases the proportion of ED patients with non-traumatic chest pain receiving a 12-lead ECG within 10 min.MethodsThis prospective single-center quasi-experimental before-after study was conducted in the T Third Affiliated Hospital of Naval Medical University from January 2023 to January 2025 and assigned to a control group and ENAF group. The ENAF group comprised (1) eight hours of nurse training, (2) an ENAF electronic template incorporating mandatory pain, anxiety, information-need and social-support items, and (3) a triage “rapid chest-pain kit”. The primary endpoint was completion of a 12-lead ECG within 10 min of triage; secondary endpoints were door-to-troponin time, ≥2-point pain reduction at 30 min, documentation completeness, ED length of stay (LOS) and 30-day major adverse cardiac events (MACE). Multivariable logistic regression adjusted for age, sex, HEART score, arrival mode and peak ED census.ResultsOf 372 screened patients, 340 met eligibility and were analyzed (170 control, 170 ENAF). Timely ECG completion increased from 60.0% to 78.2% (adjusted odds ratio 2.31, 95% CI: 1.47–3.63; P < 0.001). Median door-to-troponin time fell from 50 to 39 min (P < 0.001); pain-relief success rose from 45.3% to 61.8% (P = 0.002). Documentation completeness improved by ten percentage points (P < 0.001) and median ED LOS decreased by 0.8 h (P = 0.01). Thirty-day MACE was similar between phases (15.3% vs. 12.9%; P = 0.49), and no serious adverse events were attributed to the protocol.ConclusionsAugmenting ENAF with a structured clinical-needs module significantly accelerates ECG acquisition, improves other process metrics and enhances nursing documentation while maintaining patient safety. Adoption of this nurse-led approach could strengthen ED chest-pain pathways in comparable resource-constrained settings, and multicenter validation are warranted to establish generalizability.

Burns are injuries with local and systemic responses that cause severe complications to all systems in human body. Patients with moderate or severe burn injury are likely, over time, to develop metabolic, motor, psychiatric, and social disorders. The aim of this study was to explore the quality of life, post-traumatic stress disorder and insomnia in individuals with burninjuries. This cross-sectional study included adults with burn injuries in any area of the body. The research tools were BSHS-B, 5Q-5D-5L, ABSI, AIS, and IES-R which also included variables from medical or nursing documentation and records as well as reports from patients. Statistical significance was set at p<0.05 and analyses were conducted using SPSS statistical software (version 26.0). In the present study were enrolled 45 outpatients with burns. The findings revealed that insomnia was significantly associated with lower scores in Simple Abilities (p=0.006), Treatment Regimen (p=0.033), Heat Sensitivity (p=0.005), Affect (p<0.001), Sexuality (p=0.023), Interpersonal Relationship (p=0.046) domains of the BSHS-B index, as well as with the total BSHS-B score (p=0.004). Greater Avoidance (p=0.050) and Hyperarousal (p=0.011) domains, as also the total IES-R scores (p=0.018) of the IES-R scale were significantly associated with lower Simple abilities score of BSHS-B index. There is a clear and urgent need for the continuation of this study with a larger sample, representative of the population, and over an extended period of time to produce more sufficient and significant statistical results.

To explore the application effectiveness of an intelligent monitoring system based on multimodal sensing technology (flexible sensors, smart central processing platform, mobile medical smart terminals) in the neonatal intensive care unit (NICU) and evaluate its impact on nursing workflow restructuring, a prospective randomized controlled study was conducted. A total of 120 preterm infants admitted to the NICU of a Level-A Tertiary Hospital (the highest level in China) from January to December 2024 were randomly assigned to an observation group (n=60) and a control group (n=60). The control group received conventional wired monitoring and routine care, while the observation group utilized a multimodal intelligent monitoring system comprising flexible sensors, a smart central processing platform, a medical mobile smart terminal (PDA), and environmental sensors. The study compared the following outcomes between groups: timely identification rate and effective alarm rate of clinical events (e.g., respiratory or cardiac abnormalities), nurse response time, daily nursing documentation time, nurse activity trajectory analysis for work efficiency, and nurse workload (assessed using the NASA-TLX scale). The results showed that the observation group’s timely clinical event recognition rate and effective alarm rate were both significantly higher than the control group's (P &lt; 0.001). Both of the observation group's response time to alarm events and average daily nursing documentation time for nurses were significantly shorter than those in the control group (P &lt; 0.001). The number of trips nurses made to the nursing station for documentation decreased significantly in the observation group compared to the control group, markedly improving work efficiency. Besides, the observation group's NASA-TLX scores were superior to the control group across all dimensions (P &lt; 0.05). Conclusions can be drawn as the multimodal intelligent monitoring system accurately monitors neonatal vital signs, significantly enhances the timely identification rate and effective alarm rate of clinical events in the NICU, markedly reduces nurse response time, and substantially shortens the time nurses spend on documentation. It reconfigures the NICU's efficient nursing workflow centered on patient care and early warning, thereby improving nursing quality and ensuring patient safety, demonstrating significant clinical application value.

Home nursing care is increasing in Italy due to chronic disease expansion and population aging. This study aimed to describe the types of home nursing activities performed in two home care settings and estimate the time dedicated to them. A cross-sectional observational time-and-motion study was conducted in three local health authorities in northern and central Italy. Time spent on activities was recorded as total and average time per nurse. Average care time was estimated using linear multilevel mixed effects models. Forty-four activities were recorded across 527 visits. A total of 300 nurses (81.33% female) reported 343h of activities: 221hs (64.29%) on direct care and 123h (35.71%) on indirect activities. The most time-consuming direct activities were patient assessment (54h), pressure ulcer dressing (27h), vascular wound dressing (22h), and bandage application (21h). The longest indirect activities were managing nursing documentation (62h) and traveling to patients' homes (48h). Time nurses spent in this study on direct care outperformed the time allocated for indirect care. However, other important direct nursing activities were not performed, including family involvement in the care process and patient self-care education.

Electronic nursing documentation (END) has become an essential component of modern nursing practice. The use of END is expected to improve the quality of patient care through more accurate and efficient record keeping. This article aims to evaluate the effectiveness of electronic nursing documentation in improving the quality of patient care. This systematic review study was conducted in June-July 2024 by searching the literature on electronic databases such as ProQuest, Science Direct, PubMed, and Google Scholar for articles published between 2019 and 2024. The keywords used included “electronic nursing documentation”, or “computerized nursing documentation” and “quality of care” and “nurse” “hospital”. Two reviewers independently screened the articles, extracted data, and assessed the quality of the included studies using the Systematic Reviews and Meta-Analyses (PRISMA). There were 9 articles met the inclusion criteria and were analysed further. The inclusion criteria were RCT and non RCT, cross sectional and observational study, and hospital setting, while the exclusion criteria were qualitative study and literature or systematic review. The analysis showed that the use of END significantly improved the quality of nursing care, enhanced communication and collaboration among healthcare providers, leading to improved patient outcomes. Besides, END improved documentation accuracy, time efficiency, operational efficiency, error reduction and patient safety. However, some challenges such as monitoring and evaluation from nurse managers regarding the accuracy and quality of documentation and the need for computer skills training are also needed. It Concluded the electronic nursing documentation has great potential to improve the quality of patient care in hospitals

BackgroundNursing documentation is essential for legal accountability, continuity of care, and patient safety. While electronic nursing documentation offers advantages such as improved clarity, efficiency, and reduced workload, no nationwide study has examined which documentation types are most used in Indonesia or how nurse characteristics influence these choices. Addressing this gap is critical for guiding policy and supporting the transition to digital systems.ObjectiveThis study aimed to determine the types of nursing documentation systems most used by nurses in Indonesia and to examine nurse characteristics associated with documentation type.MethodsA cross-sectional online survey was conducted in March 2023 among 894 nurses from 34 of Indonesia’s 38 provinces. Data collected included sociodemographic characteristics, workplace settings, and documentation types (paper-based, electronic, or combination). Associations between nurse characteristics and documentation types were analyzed using the Kruskal–Wallis test, with post-hoc Mann–Whitney U tests comparing the distribution of education levels between each pair of documentation-type groups.ResultsMost participants were women (75.8%), held a diploma in nursing (53.5%), had over 12 years of work experience (35.3%), and worked in tertiary healthcare facilities (43.3%). Paper-based documentation was predominant (66.6%), followed by combination systems (24.7%) and electronic systems alone (8.7%). Paper-based use was slightly higher in Western Indonesia (66.8%) compared to Eastern Indonesia (64.8%). Education level was significantly associated with documentation type (p = 0.014). Post-hoc analysis showed that nurses using electronic documentation had higher education levels than those using paper-based (p = 0.006) or combination systems (p = 0.006), with electronic documentation most common among nurses holding a Master’s/Specialist degree (28.1%). No significant associations were found with sex, work experience, career level, service level, healthcare unit, or region.ConclusionPaper-based nursing documentation remains dominant in Indonesia, with limited adoption of electronic systems. Higher educational attainment is associated with greater use of electronic documentation, highlighting the need for improved computer literacy training, infrastructure investment, and institutional and governmental support to facilitate the transition to digital documentation.

Electronic documentation of nursing care is an important component in ensuring service quality and patient safety. However, its implementation often faces obstacles such as high workload, limited application features, unstable internet network, and organizational policies that do not provide optimal support. This study aims to analyze the relationship between workload, nurse compliance, application features, internet network, and hospital policies with the completeness of electronic documentation of nursing care at Hospital X. This study used a quantitative approach with a cross-sectional design. The sample consisted of 76 nurses consisting of 26 outpatient nurses and 50 inpatient nurses, with an accidental sampling technique. The instruments consisted of a questionnaire and an observation sheet for completeness of documentation. Validity test results &gt; 0.361 and reliability 0.89. Data analysis used the chi-square test and binary logistic regression. The results showed a significant relationship between completeness of documentation with the variables of workload (p = 0.001), nurse compliance (p = 0.001), application features (p = 0.001), and internet network (p = 0.001), while hospital policies were not significant (p = 0.071). Multivariate analysis showed that internet connection was the most dominant factor with an odds ratio of 29.7, followed by workload with an odds ratio of 23.7. Workload and internet connection quality are the dominant factors associated with the completeness of electronic nursing care documentation. Managerial intervention and infrastructure strengthening are needed to support the implementation of an effective documentation system.