<![CDATA[Background: Incomplete nursing documentation can compromise communication among healthcare professionals, continuity of care, and the evaluation of nursing outcomes. A preliminary review in the Male Internal Medicine Inpatient Ward Wing B at Dr. M. Djamil General Hospital, Padang, found incomplete documentation in 4 of 7 medical records (57.1%).Objective: This pilot case study aimed to explore changes in nursing documentation completeness following the implementation of tiered supervision using the Problem Solving for Better Health (PSBH) approach.Methods: Data were collected through observation, interviews, and review of patient medical records. Five nursing supervisors participated: one head nurse and four team leaders. Four medical records were assessed before and after the intervention, and six supervision sessions were observed. The intervention was implemented over three days within the project period of 15-24 June 2026.Results: Following the intervention, the completeness of nursing implementation documentation increased from 0% to 100%. Completeness also increased in selected evaluation entries, including subjective data (75% to 100%) and the nursing plan (50% to 75%). However, some components remained incomplete, including nursing diagnoses and expected outcomes.Conclusion: These preliminary findings suggest that tiered supervision may contribute to improved documentation completeness in selected components. Because the evaluation involved only four medical records, a short intervention period, and no control group, the findings should not be interpreted as evidence of causal effectiveness. Routine structured supervision and periodic documentation audits are recommended, alongside broader evaluation using a larger sample.]]>
