Abstract:
Nurses on duty are less aware of the importance of nursing care documentation. It is obvious in the
documentation statistics where the data of assessment, diagnosis, planning, implementation and
evaluation are sometimes empty or incomplete. The purpose of the study is to find the relationship
between individual characteristics of nurse in nursing care documentation of inpatients at Padang
Pariaman District Hospital in 2014. The research is quantitative, using analytic descriptive method
with cross sectional approach. The study was conducted by taking preliminary data at the beginning
of June until August 2014 in inpatient rooms of Padang Pariaman regional hospital. The number of
sample is 34 respondents. The sample is taken by using a total sampling method. Data collection
techniques and tools are done by using a questionnaire which are later processed by computerized
data analysis system (SPSS). The result of data analysis shows that most respondents are from age
category of young age group (94.1%); more than half of the respondents’ employment status is
volunteer (52.9%); most of the respondents’ educational background is D III (85.3%);, the majority of
the respondents are on newly working period (82.4%); more than half of the respondents are
knowledgeable (52.9%);more than half of the respondents possess negative attitude (52.9%); more
than half of the respondents have a good performance in documentation. The result of bivariat
analysis shows no relationship between age and the performance of nurse in nursing care
documentation (p>0.05); there is a relationship between employment status and the nurse’s
performance (p<0.05); there is a relationship between years of service and the nurse’s performance
(p<0.05); there is a relationship between the knowledge and the nurse’s performance (p<0.05); there
is a relationship between the attitude and the nurse’s performance (p<0.05). From the discussion
above, the writer suggests the hospital to provide theories and shared experience from the senior
nurses to the newly working nurses. One form of the theories to be given is about the importance of
proper documentation to do the continuous and sustained care process in order to reach the maximum
quality of nursing services especially in the nursing care documentation.
