CORRELATION BETWEEN NURSES’ PERCEPTION OF NURSING LEADERSHIP ROUNDS AND DOCUMENTATION COMPLIANCE IN MEDICAL RECORDS

Abstract

Background: The completeness and accuracy of nursing documentation reflect the professionalism and quality of hospital services. One effective approach to improve documentation compliance is the Nursing Leadership Round (NLR), a form of direct clinical supervision conducted by nursing leaders to provide guidance and feedback to staff nurses. Objective: This study aimed to determine the correlation between nurses’ perceptions of Nursing Leadership Rounds and their compliance with nursing documentation at Mayapada Hospital Bogor, Indonesia. Methods: This research employed a quantitative descriptive–correlational design with a total of 55 inpatient nurses selected through total sampling. Data were collected using validated and reliable questionnaires measuring perceptions of NLR and documentation compliance (Cronbach’s α = 0.961). Data analysis used Pearson’s correlation test with a significance level of p < 0.05. Results: Most respondents had moderate perceptions of NLR (63.6%) and moderate documentation compliance (58.2%). Pearson’s correlation analysis showed a significant positive correlation between nurses’ perceptions of NLR and documentation compliance (r = 0.452; p = 0.001). Conclusion: There is a significant relationship between nurses’ perceptions of Nursing Leadership Rounds and compliance with medical record documentation. Regular and structured implementation of NLR can enhance nurses’ motivation, awareness, and accountability in improving the quality of nursing documentation.