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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%)