ISSN: 2597-3851
DOI: https://doi.
org/ 10.
35747/hmj.
Homepage: https://journal.
id/index.
php/healthy Implementation of Psychosocial Nursing Care Documentation For Pneumonia Patients: A Secondary Data Analysis in an Indonesian Hospital Hesti Kurniawati1.
Maria Silvana Dhawo1*.
Maria Frani Ayu Andari Dias1 1STIKES Suaka Insan.
Banjarmasin.
South Borneo.
Indonesia *email: silvanadhawo@gmail.
ABSTRACT
Pneumonia is a respiratory disease that often requires a holistic approach in hospitals.
The psychosocial aspects of holistic care play an important role in the recovery and well-being of patients with pneumonia.
However, attention to psychosocial care for pneumonia patients, especially in nursing documentation, is still limited.
This study aims to describe the implementation of psychosocial nursing care documentation in a government general hospital using a secondary data analysis This research is a descriptive cohort retrospective study with a sample of 179 medical records selected using a purposive sampling technique.
The instrument used is a checklist sheet for the Implementation of Psychosocial Nursing Care Documentation in Pneumonia Patients.
Data analysis was carried out univariately and presented in the form of a frequency distribution table.
The results showed that the completeness of nursing care documentation was 97.
20% incomplete and 80% complete.
These findings indicate that the implementation of psychosocial nursing care documentation in pneumonia patients has not been carried out completely.
However, the assessment and recording of patient identity by nurses has been done well.
Therefore, efforts to improve the implementation of psychosocial nursing care and documentation need to be made to improve holistic services for patients, especially those with pneumonia.
Keywords: Holistic Care.
Nursing Documentation.
Pneumonia.
Psychosocial.
Quality of Healthcare Received: May 2025.
Accepted: June 2025.
Published: June 2025 A2025.
Published by Institute for Research and Innovation Universitas Muhammadiyah Banjarmasin.
This is Open Access article under the CC-BY-SA License .
ttp://creativecommons.
org/licenses/by-sa/4.
0/).
INTRODUCTION
Indonesian Basic Health Research (Riskesda.
data Pneumonia remains a significant and often fatal respiratory disease in Indonesia.
As an airborne illness, pneumonia poses a serious global health threat, affecting individuals across all age groups, elderly.
According to the Indonesian Health Profile .
, 34% of pneumonia cases occurred in toddlers, amounting to 447,431 cases.
Furthermore, children and older adults are particularly vulnerable to this disease .
The prevalence of pneumonia in Indonesia substantially burdens the healthcare system and society.
In 2019, the World Health Organization (WHO) reported that pneumonia accounted for 14% of all deaths in children under five years of age, claiming 740,180 lives globally .
The 2018 indicates that pneumonia prevalence increases with age, reaching 2.
5% in the 55Ae64 age group, 3.
0% in the 65Ae74 age group, and 2.
9% in those aged 75 and above .
Regionally, pneumonia prevalence across Indonesia's provinces.
Riskesdas 2018 identified Papua as having the highest prevalence .
0%), followed by East Nusa Tenggara .
9%), and West Papua and Gorontalo .
1%).
contrast, the Jambi and Riau Islands had the lowest prevalence .
6%).
South Kalimantan ranked 17th, with a prevalence of 3.
Within South Kalimantan.
Hulu Sungai Tengah had the highest prevalence .
4%), while Banjar Baru reported the lowest .
91%)Aipreliminary data from Dr.
Moch.
Ansari Saleh Hospital in Banjarmasin for 2022Ae2023 reveals Healthy-Mu Journal.
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counseling, patient and family education, and referrals 2022, 276 patients were under 18 years old, and 164 to psychiatrists for severe psychological issues.
were above 18.
In 2023, these numbers dropped to Additionally, family education was provided to address 186 and 160, respectively.
This suggests a decline in ineffective coping mechanisms.
Nurses documented cases as of August 2023.
Nurses play a crucial role in these interventions in the hospital's electronic medical records (E-Medical Record.
While psychosocial vaccination, and risk management, reducing disease nursing care has been implemented per the hospital's incidence and its broader impacts .
standard operating procedures (SOP.
, there has been Pneumonia often leads to psychological stress in no formal evaluation of its effectiveness.
Previous hospitalized patients, manifesting as fear, anxiety, and research at the same hospital primarily focused on These factors can adversely affect the physical care, such as managing airway clearance, patientAos quality of life, leading to sleep disturbances, without addressing psychosocial care .
reduced appetite, and diminished physical strength.
Furthermore, the documentation of psychosocial which may impair self-esteem and self-perception .
nursing care is not merely an administrative task but Despite the emphasis on bodily care, the psychosocial aspects of pneumonia treatment are equally vital.
Accurate and thorough documentation Patients frequently experience stress, anxiety, and ensures the continuity of care, allowing different depression, which can hinder recovery.
Psychosocial healthcare professionals across shifts or disciplines to nursing care provides emotional support and helps interventions provided, and responses over time.
improving their quality of life during and after serves as a vital tool for quality evaluation, enabling treatment .
A holistic approach that integrates audits and assessments of whether holistic care psychosocial nursing care is essential in general standards are being met and identifying areas for This perspective emphasizes addressing not improvement in psychosocial support services.
From a only physical health but also psychological and social legal and professional standpoint, comprehensive well-being.
Psychosocial nursing care considers family delivered, protecting both the patient and the Nurses can implement comprehensive healthcare provider.
Moreover, it facilitates effective and effective interventions by identifying non-physical communication within the healthcare team, ensuring that psychological and social factors influencing the to recovery, enhancing overall patient outcomes .
At Dr.
Moch.
Ansari Saleh Hospital, preliminary interviews with five nurses in the lung ward in 2023 high-quality patient's health are considered collectively in care planning and decision-making, ultimately contributing to more integrated and patient-centered outcomes.
revealed that psychosocial nursing care had been Given the interconnectedness of physical and applied to pneumonia patients.
However, issues such psychological health, assessing whether psychosocial as anxiety and ineffective coping mechanisms were nursing care has been implemented comprehensively common among patients and their families.
Nurses reported using interventions like relaxation therapy.
This Healthy-Mu Journal.
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Moch.
multiple hospitalizations.
Exclusion Criteria: Patients Ansari Saleh Hospital uses a secondary data analysis with a history of psychiatric or mental disorders that could affect data interpretation.
The checklist used for assessing psychosocial METHOD This nursing care documentation was adapted from retrospective design, utilizing existing records and data to achieve its objectives.
Retrospective studies such as this analyze patient medical records to evaluate Specifically, this research examines the documentation of psychosocial nursing care for pneumonia patients at Dr.
Moch.
Ansari Saleh Banjarmasin Hospital through a secondary data analysis approach.
The research population includes all medical records of pneumonia patients aged over 18 who were treated at Dr.
Moch.
Ansari Saleh Banjarmasin Hospital from 2022 to 2023.
This population comprises 164 patients from 2022 and 160 from 2023, amounting to 324 patients.
The sample for this study was 179 medical records, derived using the Slovin formula to determine the minimum sample size from the population of 324.
This sampling method ensures a representative selection of the research population.
Purposive sampling was employed to select records based on predetermined criteria relevant to the research objectives .
Purposive sampling was chosen for its ability to select a representative sample that meets the research criteria, ensuring that the data analyzed is relevant and supports the research Inclusion Criteria:
Adult patients .
ged >.
treated at Dr.
Moch.
Ansari Saleh Hospital.
Patients who received nursing care for a defined period.
Medical records that are complete and available for analysis.
Records include nursing care details, diagnoses, and interventions related to Patients with recurrent pneumonia require Assessment:
Comprising Nursing Diagnoses: Grouped into three subcategoriesAiego integrity, pain and comfort, and relational aspects.
Nursing Outcomes: Based on Interventions Implementation: Tailored to specific nursing problems.
Psychosocial Evaluation: Documenting care provided and outcomes using the SOAP method.
The checklist consisted of ten items, scored as follows: 2: Complete .
ll criteria me.
1: Incomplete .
artial criteria me.
0: Not filled .
o documentatio.
An outcome was Complete:
Incomplete: Total score <20.
Content Validity: Tested using the Content Validity Index (CVI), with an SCVI/Ave score of 4.
5 and S-CVI/UA of 1.
0, indicating substantial agreement among experts.
Reliability:
Assessed through Inter-Rater Reliability (IRR) using the CohenAos Kappa test.
A Kappa value 0.
40 and an Approximate Significance of 0.
083 indicate fair Univariate analysis was employed to analyze the data, explicitly statistics to summarize and describe individual variables.
This technique included frequency analysis to identify patterns and key findings related to each variable, providing a clear understanding of the data and the research objectives.
This study received approval from the Health Research Ethics Committee of STIKES Suaka Insan, with approval number 120/KEPKSI/V/2024.
This approval ensures adherence to ethical Healthy-Mu Journal.
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Page 9 Ae 17 e-ISSN: 2598-2095 principles such as confidentiality and the importance Table 2.
The Completeness of Psychosocial Nursing of the research findings for the public's benefit.
Care Documentation for Pneumonia Patient
The Completeness of Psychosocial Nursing Care
Documentation for Pneumonia Patient
RESULT AND DISCUSSION
Table 1.
Distribution of Frequency of the Respondents Categories Age
Gender
Length
Stay
(%)
(%)
Complete 2,80 Incomplete 19-40 y.
41-60 y.
61-80 y.
81-100 y.
Total Female 20% incomplete and only 2.
80% complete.
This Male high level of incompleteness stems from the absolute Total requirement for quality documentation, where all 1-8 Days components must be fulfilled for the documentation to 9-16 Days be considered complete.
On average, the majority of 17-24 Days the components were not fully documented.
However.
Total Total Based on Table 2, the completeness of psychosocial nursing care documentation for pneumonia patients Data on pneumonia patient records from 2022Ae 2023 at Dr.
Moch.
Ansari Saleh Regional Hospital.
The study involved 179 samples of pneumonia patients, which are presented in Table 1.
Based on the age range classification by the Indonesian Ministry of Health .
Most respondents were aged 61Ae80 .
This was followed by the 41Ae60 age group .
(Table .
These findings indicate that pneumonia cases.
Many of these patients had been treated in lung rooms such as Emerald.
Alexandria.
Jamrud.
Nilam, and Kumala.
Additionally, in 2022, an analysis of each element of psychosocial nursing care revealed that certain stages were filled out by documentation being classified as complete .
80%).
Despite this, the overall findings indicate that the incomplete, with 97.
20% of the documentation failing to meet the required standards.
Table 3.
The completeness Level of Each Psychosocial Nursing Care Documentation Component Pneumonia Patients some elderly patients with pneumonia were also diagnosed with COVID-19, as the pandemic was still prevalent during that period.
Assessment Psychosocial Nursing Care Documentati on in Pneumonia Patients The consist of four Patient Identity Assessment.
This section contains eight Complete Complete Not Filled Healthy-Mu Journal.
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Page 9 Ae 17 name, age, date of birth, address, and Physical Assessment ("Head-toToe") This section consists of six examination of the head, neck, chest, upper abdomen, and General Assessment This section includes six vital signs, health history, nutritional and status, and Psychosocial Assessment This section exclusively on into three ego integrity, pain and comfort, and Raising a Psychosocial Nursing Diagnosis:
Diagnoses are based on the Filling in Psychosocial Outcomes:
Outcomes are e-ISSN: 2598-2095 according to the identified Filling in Psychosocial Interventions:
Interventions are planned and recorded based on the diagnoses and Filling in Psychosocial Implementatio Implementatio n is according to the planned and diagnoses Filling in Psychosocial Evaluations:
Evaluations are recorded based on the nursing care provided Evaluating Psycosocial Outcomes Using SOAP:
Psychosocial outcomes are evaluated and using the SOAP (Subjective.
Objective.
Assessment.
Pla.
Format
5,02
94,98
3,35
96,08
0,55
15,65
0,55
83,80
The 16,20 6,70 77,09 16,20 6,70 77,09 16,20 6,70 77,09 16,20 83,79 psychosocial nursing care for pneumonia patients at Dr.
Moch.
Ansari Saleh Regional Hospital focuses on the process from assessment to evaluation .
The 16,20 83,80 documentation was evaluated across ten components (Table .
, with findings summarized as follows: The review included four main components: Patient Identity: This section was completed for 100% of the 179 samples, including eight categories .
ame, age, date of birth, gender, religion, address, and educatio.
16,20
6,70
77,09
Head-to-Toe Physical Assessment:
This covering six categories .
ead, neck, chest, upper Healthy-Mu Journal.
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Page 9 Ae 17 e-ISSN: 2598-2095 Complete in 5.
Incomplete in 94.
98%, and Not documented, underscoring the need for improved filled in 0%.
General Assessment: Comprising six adherence to documentation standards.
atient complaints, vital signs, health The study revealed significant findings regarding history, health patterns, nutrition, and drug us.
, the the completeness of nursing care documentation, results were: Complete in 3.
Incomplete in 08%.
Not filled in 0.
Psychosocial Assessment:
interventions for pneumonia patients.
The evaluation Divided into three subcategories .
go integrity, pain of patient identity demonstrated excellent results, with and comfort, and relational aspect.
, the results were 100% completion.
This indicates that nurses are highly Complete in 15.
Incomplete in 0.
55%, and Not filled in 83.
Psychosocial diagnoses were based on However, the head-to-toe physical psychosocial assessments.
Only one diagnosis was assessment was largely incomplete.
Observations in raised for each subcategory in response to patient the Kumala lung care room showed that nurses Documentation results showed that the conducted partial physical examinations, focusing only results were completed at 16.
20% and not filled in at on subjective and objective conditions relevant to the Outcomes were established in alignment with patient's primary complaints.
Comprehensive physical the assessments and diagnoses.
The results were examinations, such as head-to-toe assessments, were Complete in 16.
Incomplete in 6.
80%, and Not not performed as required.
filled in 77.
Interventions were documented based Butar .
highlights the importance of head-to- on the psychosocial diagnoses.
The results showed toe assessments as essential to nursing care, enabling Complete in 16.
Incomplete in 6.
70%, and Not nurses to identify physical and psychological health filled in 77.
Implementation was documented A complete physical assessment provides when nurses applied psychosocial interventions.
The critical data to address not only physical symptoms but results were Complete in 16.
Incomplete in also psychological concerns like anxiety, which can 70%, and Not filled in 77.
manifest through physical signs such as increased Evaluations blood pressure, restlessness, and nausea .
The implementation stage and documented using the SOAP general assessment was incomplete for most samples.
The results were Complete in 16.
with most nurses documenting only complaints, vital Incomplete in 6.
70%, and Not filled in 77.
This signs, and medical history.
Essential aspects such as section included evaluating both the actions provided health patterns, metabolic nutrition, and drug use and the patient's psychosocial outcomes.
Results revealed that the sample was completed at 16.
20% and Fundamentals, these elements are vital for identifying not filled in at 83.
The findings highlight disease triggers and supporting patient recovery .
A thorough and complete assessment is essential for According Nursing While identity assessments were consistently completed, other components, such as Psychosocial assessments were mostly physical and psychosocial assessments, diagnoses, incomplete or not documented at all.
Observations outcomes, interventions, and evaluations, showed low showed that nurses prioritized physical problems and Most records were incomplete or not often referred psychosocial issues to psychiatrists Healthy-Mu Journal.
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The lack of importance of holistic nursing care .
Despite using psychosocial documentation was linked to incomplete tools like SOAP (Subjective.
Objective.
Assessment, physical assessments, as psychological evaluations Pla.
, evaluations were often incomplete and focused usually rely on comprehensive physical examination solely on physical outcomes.
Observations indicated data .
that implementing nurses prioritized physical care over This explore biological, psychological, sociocultural, and undermines the holistic care model necessary for economic status, stressors, coping mechanisms, and patients with pneumonia.
social support.
The absence of these elements in The nursing care format at Dr.
Moch.
Ansari documentation limits the scope of care provided .
Saleh Hospital was based on the 3S book (SDKI.
SIKI.
Interviews with nurses revealed that while they and SLKI) but was not universally adopted.
Some occasionally addressed psychological issues, these interventions were not documented, as they were inconsistencies in documentation.
Interviews with managed collaboratively with psychiatrists.
The study medical record personnel and head nurses revealed found that most psychosocial nursing diagnoses were that updates to the nursing care format are conducted not established due to the incomplete assessment.
annually, with input from nursing staff and department Nurses predominantly documented diagnoses related Efforts are underway to integrate the 3S to physical discomforts, such as pain and nausea.
framework fully to enhance the comprehensiveness Nursing diagnoses aim to identify client responses to and efficiency of documentation.
health conditions, which are critical for effectively addressing psychosocial and physical needs .
NANDA
NIC-NOC,
To address the gaps in documentation and care delivery.
Nurses should perform complete head-to-toe Nursing care is continuous and interconnected assessments to gather comprehensive data for both .
The absence of psychosocial diagnoses affected physical and psychosocial evaluations.
Training on subsequent steps, including outcomes, interventions, psychosocial nursing care and the use of standardized guidelines like SDKI.
SLKI, and SIKI should be incomplete in over 77% of cases.
Outcomes and .
Ae.
interventions often lacked alignment with formal nursing care frameworks like SDKI.
SLKI.
SIKI, or computerized systems with standardized nursing care NANDA NIC-NOC.
Instead, nurses relied on personal models to support consistent documentation.
Annual judgment and the hospitalAos computerized system, evaluations and updates of nursing care formats which was not fully integrated with standardized should incorporate feedback from all stakeholders to ensure alignment with best practices.
Psychosocial necessary for managing the psychological impact of Beyond the observed tendency to prioritize physical pneumonia, were rarely documented.
Psychosocial complaints and make referrals for severe psychological interventions are crucial for improving emotional stability, reducing stress, and supporting compliance contribute to the with medical care.
Effective interventions can enhance psychosocial nursing care documentation observed in physical and psychological recovery, emphasizing the this study.
High workload and severe time constraints significant incompleteness of Healthy-Mu Journal.
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9 No.
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Moch.
incomplete, with 97.
20% of documentation classified Ansari Saleh Regional Hospital.
Nurses often face as incomplete and only 2.
80% as complete.
pressure to manage numerous tasks for multiple Nurses are encouraged to deliver comprehensive patients within limited shift times.
Under such nursing care encompassing physical and biological pressure, documentation, particularly for aspects aspects and thorough documentation, including head- perceived as less immediately critical or more time- to-toe physical assessments, general assessments, consuming to assess and record like psychosocial dimensions, may be deferred or overlooked in favor of interventions, implementations, and evaluations.
enhance their nursing care and documentation skills, physiological parameters.
The complexity of capturing participation in seminars or training sessions is nuanced psychosocial states might also be perceived recommended, along with seeking guidance and as demanding significant time for both assessment supervision from the head of nursing to ensure and articulation within the documentation system.
adherence to proper documentation practices.
Furthermore, the lack of specific training or comprehensive psychosocial assessments could be ACKNOWLEDGEMENT Thank you to the Director of Dr.
Moch.
Ansari another significant barrier.
While nurses are trained in Saleh holistic care principles, specialized skills in identifying, permission to the researcher to collect data at the evaluating, and documenting a wide range of Regional Hospital psychosocial responses .
eyond obvious distres.
might require further development or reinforcement.
REFERENCES