Nurses engage in various activities from the time of a patient’s admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed. A quantitative design with a retrospective approach was used, in which 240 medical records from Dr. Kariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records were randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it to be considered. The results were analyzed to compare the standard of care. It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities, according the standard of nursing activities, included the assessment of the functional status of decubitus risk (20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patients’ home needs (41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and resume activities nursing (0.8%). Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing activity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality of nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.

中文翻译：

---

基于文件的护理活动

从病人入院到出院，护士参与各种活动，帮助病人满足他们的需求。每项活动都应正确记录为真实且重要的证据。本研究旨在根据完成的文件确定护理服务中的护理活动。采用回顾性方法的定量设计，获取并评估了三宝垄 Kariadi 医院 2016 年 7 月至 9 月期间的 240 份医疗记录。这些记录是根据10种最常见的内外科疾病和住院时间超过3天的情况随机选择的。从患者进展记录中收集数据的工具使用观察表。数据使用单变量统计进行分析，并且需要至少达到特定标准的值的 80% 才能被考虑。分析结果以比较护理标准。据透露，护理活动在提供护理服务方面还不够。根据护理活动标准，这些活动包括评估褥疮风险的功能状态（20.8%）、生物学状态（0.4%）、制定护理诊断（20.8%）、识别患者的家庭需求（41.3 %）、生活质量（66.3%）、给药协作干预（60.8%）、生命体征监测（23.3%）、日常生活活动监测（37.5%）、活动/康复（37.5%）、结局（ 46.7%），并恢复护理活动（0.8%）。护理活动在医院内非常重要，必须解决患者需要的问题。每项护理活动都应产生具有批判性思维的文件。如果护理文件不清晰和准确，专业间的沟通和护理评估就无法达到最佳效果。护理活动和记录应由护士经理持续指导、控制和评估。护理活动的质量应始终保持良好，以提高患者满意度、患者安全和成本效益。