A Continuity Analysis of Independent Nursing Care Documentation Using the Fishbone Diagram in the Teratai Room North 2nd Floor X Hospital, Jakarta

  Quality nursing care documentation based on facts, accurate, complete, concise, organized, timely, easy to read, and continuity. Continuity of nursing care is fulfilled if the range of health services is appropriate, the availability of quality caregivers professionals and information related to patient care are delivered on an ongoing basis. The method used is a case study with observation, interviews, secondary data and document review. This study that is an innovation project,  uses a fish bone diagram approach to identify the causes of the discontinuity independent nursing care documentation. Documentation of evaluation of independent nursing care for the development of patients in the midwifery and ginecology room in X Hospital in Jakarta has not reflected the continuity of nursing care. The causes include the lack of optimal competence in providing independent nursing care, not optimal nursing manager functions. The continuity is overcome by optimizing the nursing manager's function by making SOP note integrated patient development, revision of midwife's job description, revision of  guide to nursing practice, electronic-based documentation system, placing midwives in accordance with the service area the authority and standard of the profession, the structured supervision schedule, and make sure the midwife's job description is in accordance with the policy.        

clinic resulted in many cases of pregnancy with hypertension problems being referred to without adequate prenatal care for treatment (5). Whereas in the USA, 50% of error medication and 20% of different drug interactions occur because of poor communication among health care providers which results in the continuity of drug delivery to patients (6).
Nurses and midwives provide nursing care in the midwifery room and Gynecology North Lt.2 t. Based on interviews, a review of the documentation of the Integrated Patient Development Note found that the independent nursing care plan set by nurses was not carried out continuously. Based on Subjective, Objective, and Assessment, Planning (SOAP) evaluation, there are evaluations and procedures for independent nursing actions at different shifts informing the continuity of care. Independent nursing actions have not been documented continuously from one change to the next. This resulted in independent nursing care given to patients not given in full but separated. The impact of non-continuity of care results in insecure care for patients.

Objectives
To identify and analyze all possible causes of the discontinuity independent nursing care documentation in Teratai North 2nd Floor, X Hospital in Jakarta.

Methods
The method used is a single instrument case study. Separate instrument case studies focus on one problem and then select a limited case to illustrate the problem (7). Data collection by observing, reviewing nursing care documents, secondary data, and interviews with nurses, nursing committees and directory of nursing. Data collection based on nursing management functions. This study is an innovation legalized by a permit Number DM 01.01/VIII.21/3209/2019 to collect data and publish the research result conducted in X Hospital in Jakarta. The results of the problem findings are analyzed using a fishbone diagram. Fishbone diagrams are used in identifying and analyzing all possible causes of problems (8).

Results
Based on the review of the nursing care document, Mrs. X who entered the Teratai North Lt.2 room on 13/10/2018 established a nursing care plan to deal with three nursing diagnoses, namely the risk of infection, the risk of injury, and pain. The goals of the nursing care plan and time criteria are not included in the nursing care plan sheet. The findings of evaluating nursing care for patients at Mrs. X at 10 a.m by nurses began without the SOAP format-describing nurses receiving new patients from the delivery room. Evaluation of subsequent nursing care using the SOAP format by the written on integrated patient development note as follows (9): 1. The nurse sets 3 diagnoses, namely: The first diagnosis of pain, the second diagnosis restores the injury, the third diagnosis the risks of infection and planning in the form of pain management, recommend relaxation techniques in injury management, install safety bed rail, control infection, check the severe preeclampsia package on 15 / 10/18. 2. Midwives on 13/10/2018 at 4.00 p.m sets two diagnoses, namely post SC severe preeclampsia, the risk of infection, with planning in the form of observing general conditions and vital signs, providing therapy according to doctor's advice, expect to off the dower catheter, and found the essential sign.
3. The nurse on 14/10/2018, the hours are not listed in the morning service, the nursing problem of the risk of infection and pain is evaluated, the risk of injury is not assessed. 4. Nurses dated 15/08/2018 at 7.30 a.m., evaluating pain nursing problems with pain management planning and check the severe preeclampsia package. At 10:45 a.m. the nurse assesses the pain resolved; the risk of infection is partially solved.
Nursing problems and nursing plans change without the analysis process of achieving the issue for resolving. Even until the patient came home also, the risk of injury had not been concluded whether partially resolved or fully resolved.
Based on the interview with one of the nurses said that independent nursing care was not yet sustainable because nurses and midwives were different in terms of diagnosing. According to the nurse, the nursing diagnosis is by the results of the assessment and attempt to address the patient's response, but the midwife's diagnosis is more similar to the medical diagnosis. This is what makes the planned nursing care not fully able to be implemented continuously. Based on his experience working together in the team said that it would be easier to perform nursing care and evaluation with SOAP nursing care for the midwives with nursing education school background then followed midwifery DIII (senior midwives) than for midwives who were initially directly DIII midwifery. The thing felt by the nurse is notifying or teaching the midwife if there are independent nursing actions.
Based on interviews with the Head of the Monitoring and Evaluation Section by nursing management functions, was concluded as follows: 1. Planning a. The job description of midwives must be able to provide midwifery care with physiological and pathological pregnancies. b. The SOP for integrated patient development note filling is being revised c. Clinic-level nursing facilitates midwifery care namely normal pregnancy, normal labor, newborns, dystocia, hemorrhagic antepartum (HAP), Pre Severe Eclampsia (severe preeclampsia), and Family Planning services.

Organizing
The allocation of midwives for each shift cannot be done 3. Staffing The placement of midwives is not yet following the area of its competence.

Direction
There is no planning to supervise nurse in nursing care documentation according to Nursing Practice Guide 5. Controlling Supervision of midwife needs planning has not been adjusted to service needs. Based on data from official schedules in the field of nursing that number 18 nursing and midwifery human resources in the room consist of: a. Head Nurse 1 person with child specialist education. b. Person In Charge Patient Service 1 person with a maternity education specialist c. Nurse as many as two people . Diploma IV Midwifery as many as one person e. Nursing D III as many as eight people f. D III Midwifery as many as five people Teratai North 2nd Floor, Midwifery and Gynecology consist of 22 beds with BOR consisting of 2 classes namely classes 1 and 2 with the recapitulation of BOR, Average Length Of Stay, TOI in the last three months as follows:  Based on the results of the nursing care documentation audit, it can be concluded that it is of good value and meets minimum service standards. However, the total amount of documentation audited amounts to only 30 patients each month from the whole patient of X Hospital, which amounts to thousands of patients.
Analysis of problem identification using fishbone diagrams Figure 1. Fishbone Diagram Figure 1 shows that not yet optimal independent nursing care documentation that is influenced by machine is critical thinking that has not been optimally applied in evaluating Subjective Assessment Planning Objectives, Integrated Patient Development Note not yet based on electronic, money, that is, there is no research related to revenue units if electronic document based systems are carried out. There is no electronic budget documentary budget on an ongoing basis, namely the placement of midwives is not in accordance with their competency area, midwifery competency in providing tertiary services is not optimal, material is Integrated Patient Development Note has not been filled according to the specified format, Standard Operating Procedure already exists The National System for Accreditation of Hospital 2018, the method of Guidance for Nursing Practices does not reflect advanced midwifery care according to the type of national referral system service, the job description of the midwife has not been adapting to the latest PMK, the documentation model is different between midwives and nurses, the criteria for the timing of nursing care plans do not yet exist, the environment is unclear writing, many use abbreviations that are not standardized, objectivity evaluation Subjective Objectives Assessment Planning does not reflect continuous patient development information , independent nursing care plans are not continuously informed. After finding out the causes of the problem, then weighting the priority of the problem is done using the following weighting aspects: 1. Magnitude (Mg): Frequent occurrence of the issues 2. Severity (Sv): The number of losses incurred 3. Manageability (Mn): Can be solved 4. Nursing concern (Nc): Focusing on nursing 5. Affordability (Af): Availability of resources Each value of each aspect is multiplied so that it gets the final value, which is the assessment of the cause of the problem. The purpose of the most priority problem is the cause of the problem with the most substantial amount.
Based on table 1, the causes of the problems identified can be prioritized as follows: 1. Standard Operating Procedures already exist but not yet by the National System for Accreditation of Hospitals 2018 2. The description of the midwife's duties has not been adjusted to the latest Minister of Health Regulation 3. Recruitment of midwives who have not met their needs 4. Placement of midwives who have not matched their competencies 5. The Nursing Practice Guide does not reflect advanced midwifery care according to the type of national referral system service 6. Midwifery competencies in providing tertiary services are not optimal 7. The Integrated Patient Development Note has not been filled in according to the specified format 8. Note Integrated Patient Development has not been based on electronics

DISCUSSION
Inaccurate, incomplete nursing care documentation reflects the continuity of nursing care. Continuity of care is one of the standards focusing on patients on assessing access to health services and sustainable services (4). Continuity of information between care providers becomes an element that influences the continuity of nursing care. The writing is not clear, cannot be read by others, the abbreviations that do not match the Indonesian language are not regulated in the technical instructions for filling in the integrated patient development note, SOP integrated patient development note, and guide to nursing practice. The use of abbreviations that are not specified in the clinic level examples P/off DC. Nursing is part of the standard of nursing language that needs to be informed to the care provider. The rule of nursing language facilitates quality data collection so that the objectivity of evaluating nursing care plans is appropriate. The standard of nursing language and the classification system of nursing diagnoses is consistently a vital element for the structure of nursing documentation and nursing plans, and nurse behaviors write standardized terminology (11,12).
The findings of subjective and objective data filling that are irrelevant to nursing diagnoses, continuous assessment is not carried out, nursing problems are not relevant to the patient's condition so that there are no appropriate planning and interventions, for example in those cases the risk of infection is related to the presence of surgical injuries inconsistent to be evaluated every day. Even the results of efforts to prevent infection with a description of the development of operating wound conditions in these patients have not been documented until the patient returns home. Inaccuracies (accuracy and quality) of nursing care plan documentation almost occur throughout the world, so it is necessary to repair and promote nursing plans and diagnoses strategically. The most important thing to improve the accuracy of nursing diagnoses is the process of critical thinking (12).
The improper writing style is one of the frequencies that often occur in diagnostic statements (13). Appropriate nursing diagnoses are connected with the existence of goals, planned interventions, and based on assessment, continuous assessment, and constant intervention. Diagnosis and objectives should be explicitly stated to be a guide to relevant interventions and evaluation of results. The most significant factor contributing to poor documentation is a failure to ensure the data needed for nursing care (13).
Documentation of nursing care properly must include the components of assessment, diagnosis, planning, implementation, and evaluation (14). The element must be clearly and sequentially documented so that all professions can understand it. The value of the audit of nursing care documentation in Hospital X has not been detailed in assessing the accuracy of the contents of the literature. Questions that can be used as instruments in auditing nursing problems, nursing diagnoses, nursing intervention plans, and nursing evaluations include (11): 1. Nursing/diagnosis problems Are nursing problems identified? Are there statements of nursing diagnoses clearly describing the priority of the problems Are current nursing problems, risks, potential identified consistently with assessment findings? Does the problem/risk statement show one or more contributing factors? Are signs and symptoms stated about nursing problems identified? 2. Purpose Is the goal formed in connection with the problem defined? Are goals patientcentered? Are the goals measurable or observable? 3. Nursing intervention plan Are nursing interventions planned to address nursing problems? Is the nursing intervention right or following the goal? Are the interventions specific and detailed? Are there interventions applied?

Nursing evaluation
Are nursing evaluations carried out in connection with planned care? Are the results of planned nursing care documented? Does the review show the effectiveness of concern in terms of achieving goals? Are nursing evaluations carried out regularly?
Planning is a managerial decision-making process that includes the depiction of the overall organization system, clarifying the vision, mission, and philosophy of the organization, estimating resources, identifying the effectiveness of actions and preparing employees to implement them (15). The planning function of the nursing field includes the sentence "implementing midwifery care in obstetrics and gynecological emergency cases, physiological and pathological pregnancies, newborns, and family planning based on midwife professional standards and ethical midwifery codes" in the midwife's job description. The authority of midwifery services that includes physiological and pathological services is guided by the Regulation of the Minister of Health Number 900/Menkes/SK/VII/2002 article 16 concerning the registration and practice of midwives (16). However, the authority of midwives in providing midwifery care in the regulation of the minister of health regarding midwife professional standards No. 369/Menkes/SK/III/2007 states the scope of midwifery services focuses on prevention, health promotion, usual delivery assistance, detection of complications in mothers and children, carrying out actions and care in accordance with authority or other aid if needed, and carrying out emergency actions (17).
The work of the executive midwife's job descriptions included the availability of midwifery care documentation in obstetric and gynecological emergency cases, physiological and pathological pregnancies, newborns, and family planning with the Nursing Clinical Practice Guide has an obstetric diagnosis for example (18) The model of midwifery is different from nursing diagnoses where nursing care focuses on the response and the existence of independent nursing actions. Accurate nursing care documentation contributes to the continuity of nursing care, safety, and patient welfare (19). To ensure the process and continuity of safe health care, Norway applies an electronic-based documentation system (2).
The staffing function in the nursing field has not been optimal in determining the type of staffing planning that will be recruited according to the priority of service needs, the placement of midwives is not by the most recent regulation of the minister of health. Also, the absence of a structured supervision schedule for documenting ongoing nursing care by the Person In Charge Patient Service. Person In Charge Patient Service is a professional staff in a hospital that implements patient service management that has a job description (20): 1. Implementation of monitoring inpatient nursing care documentation 2. Implementation of monitoring and documentation of service continuity through coordination with DPJP and other care providers.

Conclusion
Nursing care documentation has not been continuously implemented in independent nursing care actions.. Evaluation of independent nursing care contained in the integrated patient development note that uses the SOAP format has not been carried out continuously. The validation of patient development care documented by nurses and midwives at mixed patient development note have not reflected the continuity of nursing care, especially independent nursing care.
Recommendations according to nursing manager function: 1. Planning a. Within a certain period do not accept midwife HR. Accept midwives if the midwife needed in their functional area is a substitute for a retired midwife so that the excess of midwives in X Hospital can be reduced after the implementation of a tiered health service system and the limitation of midwife's authority according to the regulation of the minister of health regarding the midwife's professional standard 369/Menkes/ SK/III/2007 (17). b. The revision of the job description is adjusted to the current midwife and regulation of the minister of health professional standards. c. Revision of nursing clinic level according to midwifery care needs with the tertiary service level. d. Revision of SOP, the filling in of the integrated patient development note, must include the objectivity of the evaluation that is accurate, clear, and continuous in the care of the patient 2. Organizing The system of electronic-based documentation system so that the entire process of nursing cares from assessment to evaluation becomes an integrated part, and there is no service fragmentation and reliable information. 3.Staffing a. Place the midwife according to the service area by the authority and standard of the profession. b. Educational development for midwives by following the Midwife Certified Nurse (CNM). According to the Career guide series (2018), CNM is a nurse practitioner of advanced, specially certified and independent practice. CNM authority includes physiological midwifery care from before pregnancy, during pregnancy, after pregnancy and gynecological health services without surgery.
4. Actuating a. Person In Charge Patient Service carries out the improvement of independent nursing care documentation with a structured supervision schedule. b. Ensure that the official schedule for each shift must have at least one nurse. c. Share information between nurses and midwives in nursing care by referring to a guide to nursing practice. The form of activity can be daily in the way of reading one topic of guide to nursing practice before each service change or scheduled to be in a monthly meeting or the afternoon clinic that discusses one patient case. d. Increase patient participation to find outpatient care plans refer to patient rights and obligations (House & Hospital Accreditation Commission, 2017).

Controlling
Placement of midwives according to the scope of their services and ensuring the existence of the policy of X Hospital which guarantees that midwifery care includes physiological and pathological care, not only as outlined in job descriptions but included in Nursing By-Laws (NBL).