Completeness Documentation of Fall Risk Management: A Cross-Sectional Study.

Kartika Mawar Sari Sugianto, Rr Tutik Sri Hariyati, Annisa Rahmi Galleryzki, Elisabet Herlyani Bota Koten, Endang Sudjiati, Dadan Bardah
Author Information
  1. Kartika Mawar Sari Sugianto: Nursing Master Program, Faculty of Nursing Universitas Indonesia, Indonesia.
  2. Rr Tutik Sri Hariyati: Department of Basic Science and Fundamental Nursing, Faculty of Nursing Universitas Indonesia, Jakarta Indonesia.
  3. Annisa Rahmi Galleryzki: Nursing Master Program, Faculty of Nursing Universitas Indonesia, Indonesia.
  4. Elisabet Herlyani Bota Koten: Nursing Master Program, Faculty of Nursing Universitas Indonesia, Indonesia.
  5. Endang Sudjiati: Nursing Master Program, Faculty of Nursing Universitas Indonesia, Indonesia.
  6. Dadan Bardah: Nursing Master Program, Faculty of Nursing Universitas Indonesia, Indonesia.

Abstract

Background: Patient safety management includes the documentation of fall risks. This study aims to portray the nurses' performance toward the risk of falling management in hospitals.
Materials and Methods: A cross-sectional approach was used as the study design to measure the documentation completeness of the nursing process toward the risk of falling at hospitals during 2020. There are 110 selected medical records of hospitalized patients based on inclusion criteria such as low-risk medical records, hospitalization within 3 days, and a maximum hospitalization length of one year after the beginning of the data collection procedure. Univariate analysis is chosen to analyze the data.
Results: The results showed that nurses were inconsistent in implementing fall risk management. Furthermore, the assessment was 68.18%, where 45.45% of nurses made the nursing diagnosis, 4.55% described the problems and etiology, and also 32.72% evaluated patients' integrated records.
Conclusions: The incomplete documentation of fall risk describes the nonoptimal risk management implementation. The head nurse should develop a dynamic interaction with the fall risk patients, as well as increase nursing coordination and integration.

Keywords

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