Completeness of Critical Care Observation Chart Documentation by ICU Nurses at Hospital X, Jember: A Case Study

Abstract

Background: Nursing documentation was an essential component of critical care services because it supports communication among healthcare professionals, clinical decision-making, and patient safety. In addition to documenting nursing care through the Electronic Medical Record (EMR), ICU nurses were  also responsible for continuously recording patient monitoring data on critical care observation sheets over a 24-hour period. Objective: This study aimed to describe the completeness of critical care observation sheet documentation by nurses in the Intensive Care Unit of Rumah Sakit X Jember. Method: This study employed a descriptive case study design. The sample consisted of three critical care observation sheets that met the inclusion criteria, namely patients who had been hospitalized for more than 3 × 24 hours. Data were collected over three days using a documentation audit checklist based on the components contained in the critical care observation sheet. Result: the overall completeness of critical care observation sheet documentation ranged from 73.91% to 82.61%. The completeness rates of patient identification, hemodynamic status, neurological status, oxygenation status, and fluid and electrolyte balance documentation were 81.8–90.9%, 50–75%, 0–50%, 66.6–100%, and 100%, respectively. Neurological status documentation had the lowest level of completeness. Conclusion: the completeness of critical care observation sheet documentation by nurses in the Intensive Care Unit of Rumah Sakit X Jember has not yet reached an optimal level. Therefore, the development of standard operating procedures, standardization of nurses’ perceptions, and periodic supervision are necessary to improve the quality of nursing documentation for critically ill patients.

Keywords: nursing documentation, critical care observation sheet, intensive care unit, completeness of documentation.