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Table 1 Description of nursing activities in providing nursing care in Dr. Kariadi Hospital of Semarang (n = 240)

From: Nursing care activities based on documentation

Category

Frequency (%)

A Patient Identification

 Name

240 (100%)

 Medical record number

240 (100%)

 Age

240 (100%)

 Weight

232 (96.7%)

 Height

232 (96.7%)

B Initial Assessment

 General appearance

240 (100%)

 Consciousness level

239 (99.6%)

 Vital signs

238 (99.2%)

 History of allergy

240 (100%)

 Nutritional screening

240 (100%)

 Pain

238 (99.2%)

C Functional Status

 Barthel index

238 (99.2%)

 Risk of fall

239 (99.6%)

 Risk of pressure ulcer

50 (20.8%)

 Educational need

231 (96.3%)

 Cultural need

211 (87.9%)

D Focused Assessment

 Biology

1 (0.4%)

 Psychology

240 (100%)

 Spiritual

235 (97.9%)

 Cultural

212 (88.3%)

E Nursing Diagnosis

50 (20.8%)

F Discharge Planning

 Identification during hospitalization

239 (99.6%)

 Identification of requirements at home

99 (41.3%)

 Quality of life

159 (66.3%)

G Education

237 (98.8%)

H Intervention

 Vital signs intervention

213 (88.8%)

 Other interventions

238 (99.2%)

 Collaboration: Drug administration

146 (60.8%)

I Monitoring and Evaluation

 Monitoring vital signs

56 (23.3%)

 Monitoring activity of daily living

91 (37.9%)

 Other monitoring

239 (99.6%)

J Mobilization/Rehabilitation

90 (37.5%)

K Outcome

112 (46.7%)

L Discharge Planning/Education

 Nursing resumé

2 (0.8%)

 Initial of nurse in charge

239 (99.6%)