NURSES’ ACCURACY IN ELECTRONIC NURSING CARE DOCUMENTATION

Abstract

Electronic Medical Records (EMR) are an important instrument for ensuring service quality, patient safety, and the professional accountability of health workers, in line with Ministry of Health Regulation No. 24 of 2022. The accuracy of EMR-based nursing care documentation is a key indicator of patient safety and continuity of care, yet a preliminary study at RSU Anwar Medika revealed persistent documentation inaccuracies in several inpatient wards. This study aimed to describe nurses' accuracy in electronic-based nursing care documentation at RSU Anwar Medika. A quantitative descriptive design with an observational approach was used. The population comprised all inpatient EMRs during May 2026, totaling 942 records, with a sample of 91 EMRs obtained through consecutive sampling. Data were collected using an observation sheet referring to the hospital's Minimum Service Standards and Regulation No. 129/Menkes/SK/II/2008, then analyzed using univariate frequency distribution. Of the 91 EMRs, most documentation fell into the accurate category (83 records; 91.2%), fairly accurate (2 records; 2.2%), and inaccurate (6 records; 6.6%), with the highest accuracy found in the assessment (96.7%) and nursing diagnosis (95.6%) stages, while planning, implementation, and evaluation ranged from 92.3%. These findings indicate that documentation accuracy results from the interaction between nurses' individual readiness and system support, so future improvement should be accompanied by orientation programs for new nurses, workload evaluation, and strengthened standard operating procedures for EMR use.