Implementation of Psychosocial Nursing Care Documentation For Pneumonia Patients: A Secondary Data Analysis in an Indonesian Hospital
Abstract
Pneumonia is a respiratory disease that often requires a holistic approach in hospitals. The psychosocial aspects of holistic care play an important role in the recovery and well-being of patients with pneumonia. However, attention to psychosocial care for pneumonia patients, especially in nursing documentation, is still limited. This study aims to describe the implementation of psychosocial nursing care documentation in a government general hospital using a secondary data analysis approach. This research is a descriptive cohort retrospective study with a sample of 179 medical records selected using a purposive sampling technique. The instrument used is a checklist sheet for the Implementation of Psychosocial Nursing Care Documentation in Pneumonia Patients. Data analysis was carried out univariately and presented in the form of a frequency distribution table. The results showed that the completeness of nursing care documentation was 97.20% incomplete and 2.80% complete. These findings indicate that the implementation of psychosocial nursing care documentation in pneumonia patients has not been carried out completely. However, the assessment and recording of patient identity by nurses has been done well. Therefore, efforts to improve the implementation of psychosocial nursing care and documentation need to be made to improve holistic services for patients, especially those with pneumonia.
How strong is the evidence?
Evidence Hub reads this as a cohort study, done in people. Its evidence level is 3 of 5 (Moderate · trial / cohort / secondary analysis). Trials without a large randomized design, cohorts and secondary analyses give moderate evidence.
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