Abstract:
Documentation is an important record for nursing care in hospitals. It is evidence of nursing
implementation that uses method of nursing process approach, and record about patient response to
medical intervention, nursing intervention or reactions of patients to disease. Type of this research
was correlational study analytic with cross sectional design. The population was all of nurses in
inpatient unit in RSUD M. Zein Painan with a sample of 56 nurses. Sampling design was
proportional sampling with simple random sampling technique. This research was conducted in 18 -
31 of May, 2015. Data were collected by observation sheet and questionnaire as research
instrument.The result showed 55,4% of nurses had poor nursing documentation, 80,4% of nurses
was vocational nurse, 58,5% of nurses had worked for a long time and 57,1% of nurses had low
motivation. Chi-square test showed that there was significant correlation between education with
documentation,and motivation with documentation. But there was no significant correlation
between length of work with documentation of nursing. It’s suggested to nurses to be more fully
aware that the documentation is a thing that can’t be separated in the implementation of nursing
care and nurses need a training about documentation of nursing care to improve the quality of
nursing care especially in field of nursing documentation
