OPTIMIZATION OF NURSING CARE DOCUMENTATION COMPLETENESS TO IMPROVE THE QUALITY OF CARE AND DEFENSE AGAINST POTENTIAL MALPRACTICE LAWSUITS

Abstract

Nursing Care Documentation is an essential aspect that requires attention because the documentation results can assist in the nursing care process for patients. The poor quality of nursing care documentation in hospitals is primarily due to nurses' lack of knowledge and understanding, who often prioritize direct care over documentation, as well as a shortage of nursing staff. Incomplete nursing care documentation can impact the significance of the documentation itself, affecting legal aspects, service quality, communication, finances, education, and accreditation (Ayu & Pasaribu, 2019). Observations at Suaka Insan Hospital revealed incomplete documentation in several sections of the nursing care documentation for patient status and the absence of a Standard Operating Procedure (SOP) for Nursing Care Documentation. Of 10 patient statuses, 60% had unclear statements in the barriers section, incomplete physical examination entries, empty psychological sections, unfilled treatment assessments,
unrecorded nutritional evaluations in the initial nursing assessment, unfilled vital signs evaluations, and incomplete general patient data.In contrast, 40% of patient statuses were fully documented. Interviews with 7 nurses revealed that 3 expressed insufficient study of applying reasonable and proper documentation standards. The challenges identified included a lack of time due to high patient numbers and limited teamwork. The outcome of this activity is an increase in nurse's knowledge regarding the importance of complete nursing documentation, which impacts the quality of nursing care and helps prevent potential malpractice lawsuits.