Implementation of Nurse Unit Manager Supervision to Improve the Quality of Nursing Care Documentation Based on Electronic Medical Records (EMR)

Abstract

Structured Nurse Unit Manager Supervision to Improve the Quality of Electronic Nursing Documentation. Digital transformation through the adoption of Electronic Medical Records has not been fully accompanied by improvements in the quality of nursing documentation. An initial assessment in the inpatient wards of a teaching hospital in Depok, Indonesia, revealed that documentation was not performed in real time, the SOAP components were incomplete, and copy-paste practices persisted, rooted in the absence of structured supervision by the Nurse Unit Manager (NUM).  This project aimed to evaluate the effect of structured, digitally supported Nurse Unit Manager (NUM) supervision on the quality of electronic nursing care documentation.This single-group pre-post quality improvement project aimed to improve the quality of electronic nursing documentation through the implementation of structured NUM supervision. The activity applied management functions, Lewin’s change theory, and the Plan-Do-Study-Act cycle. Assessment was conducted through interviews, observation, and document review, analysed using SWOT and a fishbone diagram, and prioritised using the Growth-Seriousness-Manageability technique. The intervention comprised a digital NUM supervision tool piloted in one inpatient ward. A baseline audit of nine documents across three wards showed an average quality of 56% (fair). After supervision of nine nurses, quality rose to 71% (good), a 15-point increase, with the largest gain in timeliness (25% to 56%). Structured digital NUM supervision was effective in improving the quality of electronic nursing documentation. Standardisation through standard operating procedures, integration into quality indicators, and ward-wide expansion are recommended.