The Related Factors to Nursing Documentation at General Hospital Dr. Zainoel Abidin Banda Aceh

Abstract

Nursing documentation is written information resulting from the nursing process to patients. Good documentation reflects accuracy in providing services. Inadequate supervision and motivation are some problems that affected to the nursing documentation. This study aimed to determine the factors related to nursing documentation at the General Hospital dr. Zainoel Abidin Banda Aceh. This study used a quantitative study; analytic survey with a cross-sectional approach. The sample sizes are 185 respondents on nurses and 185 medical records. Data collection tools are in the form of questionnaires to the nurses and observation sheets to the medical records. Data analysis was performed with chi-square and logistic regression tests. The results showed that the variables related to nursing documentation were supervision (p-value=0.00 0) and motivation (p-value=0.008). The factor most related to nursing documentation is supervision with an OR value of 6.0 52. Supervision has the most to do with nursing documentation. Periodic supervision and the presence of new technology in terms of documentation can improve the quality of nursing documentation.