ABSTRACT
Effective communication both verbally and documentation among the health care team will improve patient safety. Nurses in carrying out the documentation starting from assessment until evaluation that must be complete within the first 24 hours since patients admitted to the inpatient ward. After 24 hours of treatment, patient progress was recorded in an integrated documentation form known as the “Integrated Nursing Progress Note”. This study aims to evaluate nursing documentation inpatient records according to the integrated nursing progress notes. It involved 141 nursing documentations systematically observed from 12 inpatient wards of Zainoel Abidin hospital was performed using a validated audit instrument. The instrument was used to assess the integrated nursing progress note of 6 steps: 4 steps focusing on the nursing documentation and two steps on time and the nurse’s identity. The study shows that the majority of the integrated nursing progress note was a complete category (79.4%). The most correctly documented items were the time (100%), subjective data (100%), objective data (100%), planning (100%) and nurse’s identity (100%), whereas the least documented items were analysis (85.3%). The researchers suggest that the hospital should conducted training of documentation regularly for the nurses to have a better understanding of integrated nursing progress note for an improvement of patient safety in the hospital ward.
