INTERNAL AND EXTERNAL DETERMINANTS OF NURSING CARE DOCUMENTATION: A SCOPING REVIEW IN INPATIENT SETTINGS
Abstrak
Nursing care documentation is an essential component of healthcare, functioning as both a communication tool among professionals and as legal evidence of nursing practice. Its completeness directly impacts patient safety, service quality, and continuity of care. This scoping review aimed to map internal and external factors influencing the completeness of nursing documentation in inpatient settings and to identify strategies for improving compliance. The review followed the PRISMA framework. Literature searches were conducted in Scopus (n=85), PubMed (n=125), and ProQuest (n=90), yielding 300 articles. After removing duplicates (n=60), automated screening (n=30), and excluding incomplete or irrelevant articles (n=30), 45 were assessed for eligibility. A total of 15 articles met the inclusion criteria (published within the last five years, in English or Indonesian, and relevant to documentation compliance) and were narratively analyzed. Findings showed nursing documentation compliance ranged from 60–80%. Internal factors included educational background, work experience, knowledge, attitudes, and motivation. External factors comprised head nurse supervision, workload, ongoing training, and support from information technology. Effective strategies to enhance documentation included structured supervision, proportional workload distribution, continuous training, and user-friendly electronic documentation systems with clear guidelines. In conclusion, improving the completeness of nursing care documentation requires not only individual effort but also systemic support. Optimizing staffing according to ward capacity and adopting integrated electronic systems can strengthen accuracy, efficiency, and consistency, thereby ensuring high-quality nursing care.
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