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Electronic nursing care documentation plays an important role in maintaining patient safety. Electronic documentation can identify the potential for increasing efficiency and effectiveness in providing nursing care. The purpose of this article is to determine the application of electronic nursing care documentation management. This research is a case study obtained when students carried out the Nursing Management Stage practice at one of the hospitals in Bogor City from 16 October - 10 November 2023. Data collection was carried out through several processes which included management review of electronic documentation based on 5M, SWOT analysis and formulation and problem priorities using the criteria of magnitude, severity, manageability, nursing concern, affordability which are assessed with a score of 1 – 5. The vision of room X is electronic-based so that effective nurses need time to adapt to technology to carry out electronic-based nursing documentation. The conclusion is that documentation of nursing care plays a crucial role as an important process for recording patient care information.

As technology develops in health, hospitals are using electronic health records. SOAP method nursing documentation is an important element in nursing services, one of the documentation that uses electronics is nursing documentation regarding handover. The aim of this research is to determine the relationship between electronic nursing documentation and handover quality. This type of quantitative research is Analytic Correlation using a cross sectional design. The population in this study was 69 nurses. Sampling used a total sampling technique so that a sample of 69 respondents was obtained. The research instrument is an observation sheet. The statistical test in this study used the Chisquare test. The results of the research obtained an overview of the relationship between the completeness of electronic nursing documentation and the quality of handover. Of the 20.3% of incomplete nursing documentation, 5.8% had good handover quality, and for complete nursing documentation 26.1% had good handover quality of 47.8%. In the chi-square analysis, the significance was p < 0.002. So Ha is accepted, meaning there is a relationship between the completeness of nursing documentation and the quality of electronic-based handover. In conclusion, the results obtained from electronic nursing documentation were mostly complete, and the quality of handover was mostly good. So it can be concluded that there is a relationship between the completeness of electronic documentation and the quality of handover.

This research aims to evaluate the differences in the use of the English language in electronic and manual documentation in nursing practice. Documentation is a crucial element in patient care, and with technological advancements, many healthcare institutions are transitioning from manual records to electronic documentation systems. The focus of this study is to identify variations in clarity, accuracy, and efficiency of nurse communication using both documentation methods.The research methodology involves surveys and document analysis on a sample of nurses engaged in both types of documentation. Surveys will assess nurses' perceptions regarding the clarity of documented information, the accuracy of information, and the efficiency of usage. The analyzed documents will include patient records, care plans, and incident reports.The research outcomes are expected to provide insights into the strengths and weaknesses of each documentation method, aiding healthcare organizations in decision-making regarding the implementation or development of documentation systems. The practical implications of this research can enhance nurse communication effectiveness and the quality of patient care, especially in the continually evolving healthcare information technology era.