Background: Nurses engage in various activities from the time of a patientâ??s admission to his or her discharge\nfrom the hospital, helping patients to meet their needs. Each of the activities should be documented properly as\nauthentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based\non the documentation completed.\nMethods: A quantitative design with a retrospective approach was used, in which 240 medical records from Dr.\nKariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records\nwere randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more\nthan 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The\ndata were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it\nto be considered. The results were analyzed to compare the standard of care.\nResults: It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities,\naccording the standard of nursing activities, included the assessment of the functional status of decubitus risk\n(20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patientsâ?? home needs\n(41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs\n(23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and\nresume activities nursing (0.8%).\nConclusions: Nursing activities are very important within the hospital and must solve the problems that the patient\nneeds. Every nursing activity should produce documentation with critical thinking. If nursing documents are not\nclear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing\nactivity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality\nof nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.
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