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Introduction: Documentation of nursing care is written evidence of care provided by nurses to patients. Quality nursing care documentation as a reflection of the quality of nursing care. Objective: To find out the quality of documentation of nursing care about how to carry out documentation of nursing care and how to complete documentation of nursing care in hospitals. Method: Literature search was carried out with 4 databases namely PubMed, ProQuest, Wiley Online Library and Google Scholar with the keywords "nursing documentation", "quality", "completeness of documentation" and "nursing care". Articles that met the inclusion criteria are articles published between 2009 and 2019, full text, in English, quantitative. Results: 6 articles with the classification of the implementation of documentation of nursing care and completeness of documentation of nursing care. Conclusion: The quality of documentation of nursing care in hospitals is still low. Therefore, to improve the quality of documentation of nursing care, it is necessary to conduct training, develop awareness, direction, and control, ongoing control, improve organizational culture, change nursing documentation from paper-based to electronic, reduce the workload of nurses by adding nursing staff and policies incentives from hospital management.
Keywords: quality, documentation, nursing care
Akademi Keperawatan Dharma Husada Kediri
Title:
Description:
Introduction: Documentation of nursing care is written evidence of care provided by nurses to patients.
Quality nursing care documentation as a reflection of the quality of nursing care.
Objective: To find out the quality of documentation of nursing care about how to carry out documentation of nursing care and how to complete documentation of nursing care in hospitals.
Method: Literature search was carried out with 4 databases namely PubMed, ProQuest, Wiley Online Library and Google Scholar with the keywords "nursing documentation", "quality", "completeness of documentation" and "nursing care".
Articles that met the inclusion criteria are articles published between 2009 and 2019, full text, in English, quantitative.
Results: 6 articles with the classification of the implementation of documentation of nursing care and completeness of documentation of nursing care.
Conclusion: The quality of documentation of nursing care in hospitals is still low.
Therefore, to improve the quality of documentation of nursing care, it is necessary to conduct training, develop awareness, direction, and control, ongoing control, improve organizational culture, change nursing documentation from paper-based to electronic, reduce the workload of nurses by adding nursing staff and policies incentives from hospital management.
Keywords: quality, documentation, nursing care.

