IMPROVEMENT LEGAL ASPECTS AND COMPLETENESS OF DOCUMENTATION USING RECORD: A REPORT OF STUDY

DOI: https://doi.org/10.35654/ijnhs.v1i2.46

Authors

  • Rr.Tutik Sri Hariyati Basic and Fundamental of Nursing Department, Faculty of Nursing, Universitas Indonesia
  • Krisna Yetti Malawat Basic and Fundamental Nursing Department Faculty of Nursing Universitas Indonesia
  • Retno Purwandari Basic and Fundamental Nursing, Faculty of Nursing, University of Jember
  • Effy Afifah Basic and Fundamental Nursing Department Faculty of Nursing Universitas Indonesia

DOI:

https://doi.org/10.35654/ijnhs.v1i2.46

Keywords:

a legal aspect of nursing documentation, completeness of nursing documentation, electronic nursing documentation

Abstract

Background: Completeness of documentation as a legal aspect and proof a nursing activity. Nothing documentation means nothing activity.
Objective: The Purpose of research to identify the legal aspect and completeness of nursing documentation after applying electronic nursing documentation.

Methods: Report study approach and using pre and post-test with the control group. Thirty Four documentation collected using consecutive sampling on one-week observation before and after using electronic nursing information. The research compared the legal aspect and completeness of data conducted before and after the implementation of the new system.
Results: The study showed improvement of the legal aspects increased by 50% (4,40 to 8,00) and completeness documentation by 10.39%  (43,00 to 49,00) after used of a system.  

Conclusion: Nursing Electronic Documentation improved legal aspect, completeness nursing and enhance the quality of nursing care.

Recommendation: Electronic nursing documentation can be done to support and increase the quality of nursing.

 

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Published

2019-01-03

Issue

Vol. 1 No. 2 (2018): International Journal of Nursing and Health Services (IJHNS)

Section

Articles