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

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


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

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References


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