Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study

International Journal of Nursing and Health Services (IJNHS) Pub Date : 2019-01-03 DOI:10.35654/IJNHS.V1I2.46

R. S. Hariyati, Krisna Yetti Malawat, Retno Purwandari, Effy Afifah

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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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使用电子护理记录改进法律方面和文件完整性:一项报告研究

背景:完整的文件作为一个法律方面和证明护理活动。没有文档就意味着没有活动。目的:探讨电子护理文件应用后护理文件的合法性及完整性。方法:报告研究方法，并与对照组采用前后测试。采用电子护理信息前后一周连续抽样，收集34份文献资料。该研究比较了新制度实施前后的法律方面和数据的完整性。结果:研究表明，在使用一个系统后，法律方面的改进增加了50%(4,40到8,000)，文件的完整性增加了10.39%(43,000到49,000)。结论:护理电子文件的应用改善了护理的法制化、完整性，提高了护理质量。建议:电子护理文件可以支持和提高护理质量。

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International Journal of Nursing and Health Services (IJNHS)

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