ABSTRACT
Research related to nursing care documentation is important to know the extent of documentation completeness in the Inpatient Prima I room of Immanuel Hospital and find out what factors influence the completeness of nursing care documentation. The purpose of this study is to identify the factors that influence nurses in achieving the completeness of nursing documentation in the primary inpatient room of the Immanuel Bandung Hospital. The population in this study was 44 nurses, consisting of both permanent nurses and contract nurses in the Inpatient Room I Prima Immanuel Hospital Bandung. The tools used are questionnaires and observation sheets. The implementation of nursing care documentation in the Prima Inpatient Room I Immanuel Hospital in Bandung has not been implemented well. The workload of nurses at Immanuel Hospital is in the light category. The nursing care documentation format at Immanuel Hospital has support categories. The leadership policy on achieving completeness of nursing care documentation is in the low category. The results of chi-square analysis showed a significant relationship between workload factors, documentation format factors, and leadership policy factors for the implementation of complete nursing care documentation in the Inpatient Prima I Room of Immanuel Hospital in Bandung with values of 0.041, 0.004 and 0.007.
