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


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.


Accidental falls, documentation, medical records, nursing diagnosis, risk management, safety management

Full Text:



Hariyati RTS, Krisna Y, Tuti A, Hanny H. Manajemen Risiko Bagi Manajer Keperawatan Dalam Meningkatkan Mutu Dan Keselamatan Pasien. 1st ed. Raja Grafindo Persada; 2019. 31‑51 p.

Morris R, O’Riordan S. Prevention of falls in hospital inpatients. J R Soc Med 2017;17:360‑2.

Radecki B, Reynolds S, Kara A. Inpatient fall prevention from the patient’s perspective: A qualitative study. Appl Nurs Res 2018;43:114‑9.

WHO. Falls. 2018. p.1-2. [ detail/falls. [Last accessed on 2021 Jan 05].

Neri RA, Lestari Y, Yetti H. Analisis pelaksanaan sasaran keselamatan pasien di rawat inap Rumah Sakit Umum Daerah Padang Pariaman. J Kesehat Andalas 2018;7:48‑55.

Johnson K, Scholar H, Stinson K, Nea‑Bc, Sherry Razo MA, Nea‑Bc. Patient fall risk and prevention strategies among acute care hospitals. Appl Nurs Re. 2020;51:151188.

Hariyati RTS, Handiyani H, Utomo B, Rahmi SF, Djadjuli H. Nurses’ perception and nursing satisfaction using “The Corner Competency System.” Enferm Clín 2019;29:659‑64.

Jones A, Johnstone MJ. Managing gaps in the continuity of nursing care to enhance patient safety. Collegian 2019;26:151‑7.

Widiasari W, Handiyani H, Novitasari E. Kepuasan pasien terhadap penerapan keselamatan pasien di rumah sakit. J Keperawatan Indones 2019;22:43‑52.

Nilasari P, Hariyati RTS, Siti A. Analisis Swot Asuhan Keperawatan Yang Terlewatkan. J Keperawatan Stikes Kendal 2020;12:125‑34.

Hajduchova H, Brabcova I, TothovaV, BartlovaS, Dosedel M, Maly J, et al. Factors associated with falls in hospitals : Outcomes for nursing care 2019;1‑7.

Kurniawan MH, Tutik R, Hariyati S. Patient assessment responses in nursing practice to enhance patient safety : A Patient assessment responses in nursing practice to enhance patient safety : A systematic review. Enferm Clín 2019;29:459‑63.

West GF, Rose T, Throop MD. Assessing nursing interventions to reduce patient falls. Nursing (Lond) 2018;48:59‑60.

Permanasari VY. Compliance of the nurse for fall risk assessment as a procedure of patient safety: A systematic review. KnE Life Sciences/The 2nd International Conference on Hospital Administration. 2019. p. 207‑19.

Sanjaya PD, Rosa EM, Ulfa M. Evaluasi penerapan pencegahan pasien berisiko jatuh di rumah sakit. Jurnal Fakultas Kesehatan Masyarakt 2017;11:105-13.

Komisi Akreditasi RS. Instrumen survei standar nasional akreditasi rumah sakit. 2018;Vol.1.1. p.172‑226.

Higaonna M, Enobi M, Nakamura S. Development of an evidence‑based fall risk assessment tool and evaluation of interrater reliability and nurses ’ perceptions of the tool ’ s clarity and usability. Japan J Nurs Sci 2017;14:146‑60.

Zhao Y, Bott M, He jianghua, Kim H, Hye PS, Nancy D. Multilevel factors associated with injurious falls in acute care hospitals. J Nurs Qual Care 2018;33:20‑8.

Alves VC, Freitas WCJ De, Ramos JS, Chagas SRG, Regina L. Actions of the fall prevention protocol : Mapping with the classification of nursing interventions. Rev Lat Am Enfermagem 2017;25:e2986.

Nur HA, Dharmana E, Santoso A. Pelaksanaan asesmen risiko jatuh di rumah sakit the implementation of falls risk assessment in the hospital. Indones J Nurs Midwifery 2016;7642:123‑33.

Nanda I. Nursing diagnoses. 2020. p. 1–2.

Ha S, Lee M. A study on patient safety culture, incident reporting and safety care activities of clinical nurses in a university‑affiliated hospital. J Muscle Jt Heal 2019;26:35‑45.

Moon S, Lee J. Correlates of patient safety performance among nurses from hospitals with less than 200 beds. Korean J Adult Nurs 2017;29:393‑405.

Ünver S, Yeniğün SC. Patient safety attitude of nurses working in surgical units: A cross‑sectional study in Turkey. J Perianesthesia Nurs 2020;35:671‑5.

Ko YK, Jeong SH, Yu S. Job autonomy, perceptions of organizational policy, and the safety performance of nurses. Int J Nurs Pract 2018;24:e12696.

Yang YK. Factors influencing safety care activities of hospital nurses. J Korean Acad Fundam Nurs 2019;26:188‑96.

Abu‑El‑Noor NI, Abu‑El‑Noor MK, Abuowda YZ, Alfaqawi M, Böttcher B. Patient safety culture among nurses working in Palestinian governmental hospital: A pathway to a new policy. BMC Health Serv Res 2019;19:550.

Galleryzki AR, Hariyati RTS, Afriani T, Rahman LO. Hubungan sikap keselamatan dengan implementasi sasaran keselamatan pasien oleh perawat di rumah sakit. J Kepemimpinan dan Manajemen Keperawatan 2021; 4: p.11‑12..

Al‑Mugheed K, Bayraktar N. Patient safety attitudes among critical care nurses: A case study in North Cyprus. Int J Health Plann Manage 2020;35:910‑21.

Elsous A, Akbari Sari A, AlJeesh Y, Radwan M. Nursing perceptions of patient safety climate in the Gaza Strip, Palestine. Int Nurs Rev 2017;64:446‑54.

Dewi AN, Arso SP FE. Analisis pelaksanaan program keselamatan pasien di unit rawat inap rs wava husada kabupaten malang. J Kesehat Masy 2019;7:20‑30.

Dewi T, Noprianty R. Phenomenologi study: Risk factors related to fall incidence in hospitalized pediatric patient with theory faye G. Abdellah. Nurse Line J 2018;3:81.

Nopriyanto D, Hariyati RTS, Ungsianik T. Peningkatan pendokumentasian catatan perkembangan pasien terintegrasi melalui penguatan peran kepala ruang dengan pendekatan teori orlando. Holistik J Kesehat 2019;13:19‑28.


  • There are currently no refbacks.