Implementation of nursing documentation audit in all hospital units

Oct 13, 2025 by wbrum.org 107 views

Introduction

Nursing documentation audit is a crucial activity that aims to assess and improve the quality of nursing services provided by nurses. In the intensive care room of Santa Elisabeth Hospital Medan, this activity is vital to ensure that nurses can carry out their duties carefully and reduce the potential for errors in nursing care for patients. The development of nursing documentation audits is essential to improve the quality of services in this critical unit. This study aims to explore the development of nursing documentation audits in the intensive care room of Santa Elisabeth Hospital Medan.

Background

Nursing documentation audit is a sustainable activity that involves assessing and improving the quality of nursing services provided by nurses. It is a critical component of quality improvement initiatives in healthcare settings. The audit process involves evaluating the completeness, accuracy, and timeliness of nursing documentation, as well as identifying areas for improvement. In the intensive care room, nursing documentation audit is particularly important due to the high-stakes nature of patient care.

Methodology

This study used an action research design, which involves a collaborative approach between researchers and practitioners to address a specific problem or issue. The study involved 19 nurses from the intensive care room as participants. The data collection instruments used in this study included guidelines for focus group discussions, questionnaires on nursing knowledge and satisfaction about nursing documentation audits, and documentation evaluation instruments from the Ministry of Health of the Republic of Indonesia. The data obtained was analyzed qualitatively and quantitatively to provide a comprehensive picture of the audit implementation.

Results

The results of this study showed the formation of the Nursing Documentation Audit Team, which was complemented by a clear job description. The team also compiled a systematic documentation audit flow for intensive care rooms. The audit team's assessment revealed that the level of completeness of nursing documentation in this unit only reached 69%. Although there was an increase in nurses' knowledge regarding nursing documentation audits, there was no significant difference in nurse satisfaction with the process.

Discussion

The results of this study highlight the importance of nursing documentation audit in improving the quality of nursing services. The formation of the Nursing Documentation Audit Team and the development of a systematic documentation audit flow are crucial steps in ensuring that nursing documentation is accurate, complete, and timely. However, the results also suggest that there is still a need for improvement in nursing documentation practices, particularly in terms of completeness.

Conclusion

This study contributes to the body of knowledge on nursing documentation audit and its role in improving the quality of nursing services. The findings of this study suggest that nursing documentation audit is a critical component of quality improvement initiatives in healthcare settings. The study also highlights the importance of nursing documentation audit in maintaining and improving the quality of health services.

Recommendations

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

Implementation of nursing documentation audit in all hospital units: The managerial hospital should implement a nursing documentation audit in all hospital units to ensure that all nurses can be trained and accustomed to good documentation practices.
Training and development of nurses' skills: Administrator nurses are expected to prepare training and development of nurses' skills, as well as providing facilities that support the implementation of effective nursing documentation audits.
Consistent application of nursing documentation audit: A consistent application of nursing documentation audit is expected to increase the quality of treatment given to patients, which will have a positive impact on the overall hospital services.

Limitations

This study has several limitations, including:

Small sample size: The study involved a small sample size of 19 nurses from the intensive care room.
Limited generalizability: The findings of this study may not be generalizable to other healthcare settings.

Future Research Directions

Future research should focus on:

Large-scale implementation of nursing documentation audit: Future studies should aim to implement nursing documentation audit in a larger scale to ensure that the findings of this study can be generalized to other healthcare settings.
Evaluation of the effectiveness of nursing documentation audit: Future studies should evaluate the effectiveness of nursing documentation audit in improving the quality of nursing services.

Conclusion

In conclusion, this study highlights the importance of nursing documentation audit in improving the quality of nursing services. The findings of this study suggest that nursing documentation audit is a critical component of quality improvement initiatives in healthcare settings. The study also highlights the importance of nursing documentation audit in maintaining and improving the quality of health services.

Q: What is nursing documentation audit?

A: Nursing documentation audit is a sustainable activity that aims to assess and improve the quality of nursing services provided by nurses. It involves evaluating the completeness, accuracy, and timeliness of nursing documentation, as well as identifying areas for improvement.

Q: Why is nursing documentation audit important?

A: Nursing documentation audit is important because it helps to ensure that nurses can carry out their duties carefully and reduce the potential for errors in nursing care for patients. It also helps to improve the quality of nursing services and maintain and improve the quality of health services.

Q: What are the benefits of nursing documentation audit?

A: The benefits of nursing documentation audit include:

Improved quality of nursing services: Nursing documentation audit helps to ensure that nursing documentation is accurate, complete, and timely, which improves the quality of nursing services.
Reduced errors: Nursing documentation audit helps to reduce the potential for errors in nursing care for patients.
Improved patient safety: Nursing documentation audit helps to ensure that patients receive safe and effective care.
Improved patient satisfaction: Nursing documentation audit helps to ensure that patients receive high-quality care, which improves patient satisfaction.

Q: How is nursing documentation audit implemented?

A: Nursing documentation audit is implemented through a systematic process that involves:

Formation of a nursing documentation audit team: A team of nurses is formed to oversee the implementation of nursing documentation audit.
Development of a systematic documentation audit flow: A systematic documentation audit flow is developed to guide the audit process.
Evaluation of nursing documentation: Nursing documentation is evaluated to ensure that it is accurate, complete, and timely.
Identification of areas for improvement: Areas for improvement are identified and addressed through training and development of nurses' skills.

Q: What are the challenges of implementing nursing documentation audit?

A: The challenges of implementing nursing documentation audit include:

Resistance to change: Nurses may resist changes to their documentation practices.
Lack of resources: Hospitals may lack the resources needed to implement nursing documentation audit.
Complexity of the audit process: The audit process can be complex and time-consuming.

Q: How can nursing documentation audit be sustained?

A: Nursing documentation audit can be sustained through:

Continuous monitoring and evaluation: Continuous monitoring and evaluation of nursing documentation audit is essential to ensure that it remains effective.
Training and development of nurses' skills: Training and development of nurses' skills is essential to ensure that nurses are equipped to implement nursing documentation audit.
Support from hospital administrators: Support from hospital administrators is essential to ensure that nursing documentation audit is implemented and sustained.

Q: What are the future directions for nursing documentation audit?

A: The future directions for nursing documentation audit include:

Large-scale implementation: Nursing documentation audit should be implemented on a large scale to ensure that it is effective in improving the quality of nursing services.
Evaluation of the effectiveness of nursing documentation audit: The effectiveness of nursing documentation audit should be evaluated to ensure that it is meeting its goals.
Development of new tools and technologies: New tools and technologies should be developed to support the implementation of nursing documentation audit.