INCREASE THE COMPLETENESS OF THE NURSING DOCUMENTATION THROUGH THE IMPLEMENTATION OF THE NURSING INITIAL ASSESSMENT FORMS

Nu rse  had limited time t o perform nursing documentation  due to dense  work load and limited number of nurse as well as the narrative format of documentation. Therefore, nursing assessment documentation was frequently incomplete. The study  aim  was  to determine the effect of initial nursing assessment form aton the completeness of nursing assessment documentation in the internal ward  of Padang  Panjang District Hospital in year 2016. The study design was  action research. Bivariate analysis was done by W ilcoxon ’s  test and multivariate analysis was done by F riedman ’s  test. R esult showed that  the implementation of nursing initial assessment checklist form at  increase the completeness of the nursing initial assessment documentation  (p = <0.05). N ursing initial assessment checklist form at could be applied to improve the completeness of nursing assessment documentation. It is r ecomme nded to  hospital  management to set  the nursing initial assessment checklist form at  as the standard form at  usedand provide supervision and evaluation of this program . Key w ords : checklist, in nitial a ssessment, d ocumentation