Internal and External Determinants of Nursing Care Documentation: A Scoping Review in Inpatient Settings

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Discussion

Scoping review maps influences on nursing care documentation compliance in inpatient settings, highlighting internal and external factors.

Nursing documentation compliance ranges from 60–80%, impacting patient safety and care quality.
Internal factors influencing documentation include educational background, motivation, and work experience.
External factors like head nurse supervision and workload affect documentation completeness.
Strategies for improvement involve structured supervision and user-friendly electronic documentation systems.

Soekerno et al. (2025) studied this question.

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Scoping review maps influences on nursing care documentation compliance in inpatient settings, highlighting internal and external factors.