| Summary: | Background: Medical record documentations must be accomplished because
they contain memories used as source material for the accountability report of
the hospital. Documentation shall be conducted in every medical service,
especially by nurses providing nursing care. The significance of nursing care
documentation can be viewed from several aspects, among which are the
legal aspects, quality of service, communication, finance, education, research
and accreditation.
Evaluation and research on nursing documentation has not been
implemented in Muntilan hospital, in fact nursing documentation is crucial in
providing nursing care. Relevant research on nursing care documentation is,
therefore, necessary.
Objective: To determine the relationship between the knowledge and
attitudes of nurses with their compliance in nursing care documentation.
Method: This is an analytical research with quantitative and qualitative
methods that employed cross sectional research design
Results: The results demonstrated no significant correlation between
knowledge and documenting compliance, R =- 0.061 and P = 0.581, attitude
and documenting compliance also showed no correlation R = 0.013 and P =
0.904. Similarly, internal factors of nurses, such as education, years of
service, type of employment and income outside of wages, did not affect the
documenting compliance. In contrast, external factors such as nursing
facilities, procedures, supervision and nursing care systems used might affect
the compliance of nursing care documentation.
Conclusion: No relationship was found between knowledge and attitudes of
nurses with the compliance of nursing care documentation, nor was between
the internal factors of nurses and the compliance documentation. However,
external factors of nurses had influence on the compliance of nursing care
documentation at Muntilan Hospital.
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