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ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 6  |  Page : 517-521

Completeness documentation of fall risk management: A cross-sectional study


1 Nursing Master Program, Faculty of Nursing Universitas Indonesia; Inpatient Department, Ciawi Public Hospital, Indonesia
2 Department of Basic Science and Fundamental Nursing, Faculty of Nursing Universitas Indonesia, Indonesia
3 Nursing Master Program, Faculty of Nursing Universitas Indonesia; Nursing Department, Sekolah Tinggi Ilmu Kesehatan Kepanjen, Indonesia
4 Nursing Master Program, Faculty of Nursing Universitas Indonesia, Indonesia
5 Nursing Master Program, Faculty of Nursing Universitas Indonesia; Nursing Division, Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia

Correspondence Address:
Rr Tutik Sri Hariyati
Jl. Prof. Dr. Bahder Djohan, Kampus UI Depok Jawa Barat 16424
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.ijnmr_109_21

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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.


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