Identifying Nurses’ Challenges with Patient Documentation in Indonesia

Nursing documentation reflects the quality in patient care. However, nursing documentation remains
problematic in Indonesia. Paper based patients report were applied in most hospitals in the country. A
qualitative approach through several focus group discussions with head nurses and their staff was
conducted to identify problems that hinder the nurses from proper documentation procedure in an
urban hospital in Indonesia. The open-ended questions regarding comments about on nursing
documentation process were considered. The results of the study were captured in three themes and
subthemes: (1) Inadequate supervision for nurses on nursing documentation: The importance of
documentation; organizational support, (2) competencies issue on documentation: Nurses’
educational diversity, (3) Lack of confidence and motivation on documentation: Workload issues;
nursing leadership. The study have implication upon the need for support and simultaneous
educational intervention to ensure adherence on the guided nursing documentation procedure.

Author(s) Details

Hajjul Kamil
Nursing Leadership and Management Department, Faculty of Nursing, Syiah Kuala University, Jalan tengku Tanoh Abee Darussalam, 23111 Banda Aceh, Indonesia.

Elly Wardani
Nursing Leadership and Management Department, Faculty of Nursing, Syiah Kuala University, Jalan tengku Tanoh Abee Darussalam, 23111 Banda Aceh, Indonesia.

R. Rachmah
Nursing Leadership and Management Department, Faculty of Nursing, Syiah Kuala University, Jalan tengku Tanoh Abee Darussalam, 23111 Banda Aceh, Indonesia.

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