Benefits of Documentation of Nursing Care

Oct 13, 2025 by recoveryshake.com 91 views

Introduction

Documentation of nursing care is a crucial aspect of patient care, as it provides a comprehensive record of the patient's medical history, treatment, and progress. At the Gunung Tua Regional General Hospital in North Padang Lawas Regency, the experience of nurses in documenting nursing care was the focus of a study conducted in 2014. Despite the importance of documentation, many nurses struggle to carry out this task accurately and completely. This study aimed to explore the experience of nurses in the documentation process.

Background

Documentation of nursing care has been recognized as a vital component of patient care for decades. It serves as a communication tool between healthcare professionals, a basis for decision-making, and a means of evaluating the quality of care provided. However, the process of documentation can be challenging, especially in hospitals with limited resources and high workloads. The study conducted at the Gunung Tua Regional General Hospital aimed to investigate the experience of nurses in documenting nursing care and identify the factors that influence this process.

Methodology

This qualitative study employed a phenomenological design, which aimed to gain a deeper understanding of the experience of nurses in documenting nursing care. Nine nurses were selected as participants through purposive sampling, and in-depth interviews were conducted to collect data. The Colaizzi method was used to analyze the data, which consisted of seven steps:

Initial Coding: The researcher read and reread the interview transcripts to identify initial codes.
Clustering: The initial codes were grouped into clusters based on their similarity.
Identifying Themes: The clusters were analyzed to identify themes that emerged from the data.
Defining Themes: The themes were defined and refined to ensure that they accurately represented the experience of nurses in documenting nursing care.
Looking for Patterns: The researcher looked for patterns and relationships between the themes.
Identifying Subthemes: Subthemes were identified within each theme to provide a more detailed understanding of the experience of nurses.
Refining the Themes: The themes and subthemes were refined to ensure that they accurately represented the experience of nurses in documenting nursing care.

Results

The analysis of the data revealed four main themes related to the experience of nurses in documenting nursing care:

Documentation Phase

The documentation phase includes the assessment, diagnosis, planning, implementation, and evaluation of nursing care. However, the study found that not all stages were well documented, which could affect the quality of care provided to patients. The nurses reported that they often struggled to document the care provided, especially during busy periods.

Inhibiting Factors

The study identified several inhibiting factors that affected the implementation of documentation of nursing care. These factors included:

Lack of Time: Nurses reported that they often did not have enough time to document the care provided, especially during busy periods.
High Workload: The high workload of nurses made it difficult for them to document the care provided.
Lack of Training: Nurses reported that they did not receive adequate training on the importance of documentation and how to document care efficiently.
Lack of Support: Nurses reported that they did not receive adequate support from their colleagues and hospital management to document the care provided.

Nurse's Expectations

The nurses reported that they expected a better system and support from the hospital to make it easier for them to document the care provided. They also hoped that there would be further training on appropriate and efficient documentation practices.

Benefits of Documentation of Nursing Care

A good documentation does not only function as a medical record, but also as a communication tool between members of the health team, as well as a basis for decision-making in patient care. With complete documentation, the quality of health services can be improved, which in turn has a positive impact on patients.

Conclusion

The study found that the implementation of documentation of nursing care in the Gunung Tua Regional General Hospital was not optimal. Support is needed from all parties, including hospital and colleagues, to overcome various existing inhibiting factors. Through improvement in the documentation system, it is expected that the quality of nursing care can be increased and have a positive impact on patients served.

Recommendations

Based on the findings of this study, the following recommendations are made:

Improve the Documentation System: The hospital should improve the documentation system to make it easier for nurses to document the care provided.
Provide Adequate Training: Nurses should receive adequate training on the importance of documentation and how to document care efficiently.
Increase Support: Nurses should receive adequate support from their colleagues and hospital management to document the care provided.
Monitor the Quality of Care: The hospital should monitor the quality of care provided to patients to ensure that it meets the standards of care.

Q: What is the importance of documentation of nursing care?

A: Documentation of nursing care is a crucial aspect of patient care, as it provides a comprehensive record of the patient's medical history, treatment, and progress. It serves as a communication tool between healthcare professionals, a basis for decision-making, and a means of evaluating the quality of care provided.

Q: What are the inhibiting factors that affect the implementation of documentation of nursing care?

A: The study identified several inhibiting factors that affected the implementation of documentation of nursing care, including:

Lack of Time: Nurses reported that they often did not have enough time to document the care provided, especially during busy periods.
High Workload: The high workload of nurses made it difficult for them to document the care provided.
Lack of Training: Nurses reported that they did not receive adequate training on the importance of documentation and how to document care efficiently.
Lack of Support: Nurses reported that they did not receive adequate support from their colleagues and hospital management to document the care provided.

Q: What are the benefits of documentation of nursing care?

A: A good documentation does not only function as a medical record, but also as a communication tool between members of the health team, as well as a basis for decision-making in patient care. With complete documentation, the quality of health services can be improved, which in turn has a positive impact on patients.

Q: What are the recommendations for improving the documentation of nursing care?

A: Based on the findings of this study, the following recommendations are made:

Improve the Documentation System: The hospital should improve the documentation system to make it easier for nurses to document the care provided.
Provide Adequate Training: Nurses should receive adequate training on the importance of documentation and how to document care efficiently.
Increase Support: Nurses should receive adequate support from their colleagues and hospital management to document the care provided.
Monitor the Quality of Care: The hospital should monitor the quality of care provided to patients to ensure that it meets the standards of care.

Q: How can the hospital improve the documentation of nursing care?

A: The hospital can improve the documentation of nursing care by:

Implementing a user-friendly documentation system: The hospital should implement a documentation system that is easy to use and navigate.
Providing regular training: Nurses should receive regular training on the importance of documentation and how to document care efficiently.
Increasing support: Nurses should receive adequate support from their colleagues and hospital management to document the care provided.
Monitoring the quality of care: The hospital should monitor the quality of care provided to patients to ensure that it meets the standards of care.

Q: What are the implications of this study for nursing practice?

A: This study has implications for nursing practice, as it highlights the importance of documentation of nursing care and the need for nurses to receive adequate training and support to document care efficiently. It also emphasizes the need for hospitals to improve their documentation systems and provide regular training to nurses.

Q: What are the limitations of this study?

A: This study has several limitations, including:

Small sample size: The study only involved nine nurses, which may not be representative of the entire nursing population.
Qualitative design: The study used a qualitative design, which may not be generalizable to other settings.
Limited scope: The study only focused on the experience of nurses in documenting nursing care and did not explore other aspects of nursing practice.