Background: This study is the achievement of nursing compliance targets in the implementation of documentation at Immanuel hospital, this data obtained from a preliminary study of open medical record review (OMRR) providing education to 20 medical records of patients with the results of documentation on the assessment of patient education needs 85%, on planning of 70% education provision, 70% nursing education implementation and evaluation, namely veriﬁcation of the understanding of education provided 80%.
Objectives: The study aimed to describe of nursing compliance with documenting the provision of education to patients and families in the inpatient room of Immanuel hospitalin Bandung which includes Compliance with Assessment / assessment, planning, implementation and evaluation
Methods: This study was conducted using descriptive method with quantitative approach. The total sample in this study was 55 subjects that selected using pruposive sampling techniques. Data collection uses observation sheets that have been tested for validity and reliability and the dataanalyzed using a frequency distribution.
Results: The statistic data shows that majority of the subjects were obey (78.2%) in documenting the assessment, almost all of the subjects wereobedient (94.6%) in documenting planning, more than half were obedient (69.1%) in documenting implementation, and also complied (67.3%) in documenting evaluations.
Conclusion:The level of nurses’ compliance with documenting the provision of education to patients and families illustrates that all nurses adhere to documentation, from the stages of assessment, implementation to evaluation. Recommendation the next research is to examine the function of the head room management to the completeness of the documentation of the nursing process, especially the provision of education.