Factors Influencing Writing Completeness of Nursing Documentation a Literature Review

Abstract

The quality of service at the hospital can be seen from the implementation of nursing care documentation. Documentation is useful for hospitals in improving accreditation standards/JCI (Joint Commission International) as a communication tool between professions, quality service indicators, evidence of nurse responsibility and accountability, data sources and as a research tool. Nursing care documentation is carried out as evidence of nursing actions taken professionally and legally so as to provide protection to nurses and patients. The method used in writing this article is a Literature Review through several stages, namely making questions, identification, eligibility, selection of article inclusion and screening. The selection process is stated in the literature review framework and the results of 8 articles from national and international journals are obtained. From the results of a review of journals conducted, it shows that almost all studies conducted have the same results related to the factors that affect the completeness of nursing documentation. The influencing factors include age, knowledge level, education level, motivation, workload, tenure and supervision of the head of the room. It can be concluded that there is a significant relationship between the factors that influence the completeness of nursing documentation including age, level of knowledge, level of education, motivation, workload, tenure and supervision of the head of the room. Therefore, the completeness of nursing documentation is very important to improve quality of service in hospitals.