Analysis of the Quality, Challenges, and Nurses’ Needs and Readiness for the Implementation of Electronic Nursing Documentation in Provincial Hospitals of South Sulawesi

Abstract

Background: Nursing documentation is an integral component of the nursing care process that serves as a professional communication tool, legal evidence, and an indicator of healthcare service quality. However, in practice, the quality of nursing documentation in hospitals still faces various challenges, including incomplete records, inconsistency with nursing process standards, and limited utilization of information technology-based documentation systems. These conditions may negatively affect service quality and patient safety. Objective: To analyze the quality of nursing documentation and identify the challenges faced by nurses in implementing nursing documentation in hospitals in South Sulawesi Province. Methods: This study employed a descriptive-analytic approach through a literature review and analysis of nursing documentation practices in hospitals in South Sulawesi Province. Data were obtained from scientific journals, research reports, and relevant sources related to nursing documentation and its influencing factors. Conclusion: The quality of nursing documentation in hospitals in South Sulawesi Province has not yet reached optimal standards and is influenced by several challenges, including high nursing workload, limited time, uneven documentation competencies, and the predominance of manual documentation systems. Efforts to improve nursing documentation quality require strengthening nurses’ competencies, enhancing managerial support, and developing sustainable electronic nursing documentation systems.