KUALITAS PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUANG RAWAT INAP (Studi di RSUD Kalimantan Tengah)

Abstract

ABSTRAK Pendokumentasian asuhan keperawatan yang tidak lengkap mengakibatkan mutu Rumah Sakit akan menurun. Penelitian ini bertujuan untuk mengetahui gambaran kualitas pendokumentasian asuhan keperawatan di ruang rawat inap RSUD di Kalimantan Tengah. Penelitian ini bersifat deskriptif analitik. Jumlah sampel penelitian ini sebanyak  222 rekam medis yang dilakukan dengan teknik sampling Cluster Random Sampling. Instrumen penelitian menggunakan lembar observasi 37 penilaian kualitas pendokumentasian asuhan keperawatan. Hasil penelitian menunjukan bahwa gambaran kualitas pendokumentasian asuhan keperawatan dari pengkajian tidak sesuai (100%), Perencanaan ( penentuan diagnosis, penentuan tujuan/kriteria hasil, pembuatan intervensi keperawatan) dari 120 rekam medis (54%) sesuai, Implementasi 200 rekam medis (90%) sesuai dan Evaluasi 142 rekam medis (64%) sesuai. Gambaran kualitas pendokumentasian asuhan keperawatan di ruang rawat inap RSUD di Kalimantan Tengah berkualitas dengan sebanyak 124 rekam medis (55,9%) dan tidak berkualitas sebanyak 98 rekam medis (44,1%). Pendokumentasian asuhan keperawatan yang tidak lengkap dapat menurunkan mutu pelayanan di Rumah Sakit sehingga disarankan perawat dapat terus menjaga kualitas penulisan asuhan keperawatan sesuai dengan standar yang ditetapkan.   Kata Kunci : Kualitas, Pendokumentasian Asuhan Keperawatan ABSTRACT Incomplete nursing documentation leads to a deterioration in the quality of the hospital. This search is to know the description of the quality of nursing literature in the RSUD inpatient ward Jaraga Sasameh Buntok, Regency of South Barito. This search is a descriptive analysis. The number of samples in this study was 222 medical records performed using the cluster random sampling technique. The finding aid used an observation sheet to assess the quality of nursing documentation. The results showed that the description of the quality of nursing care resulting from the evaluation was not appropriate (100%), the planning of 120 medical files (54%) was appropriate, the implementation of 200 files Medical (90%) was appropriate and the assessment of 142 medical records (64%). The description of the quality of nursing documentation in the ward of the RSUD Jaraga Sasameh Buntok is essentially quality, with 124 medical records (55.9%) and some unskilled out of 98 (44.1%). Incomplete nursing care documentation may reduce the quality of service in the hospital, so it is recommended that nurses continue to maintain the quality of nursing care writing in accordance with established standards. Keywords: quality, nursing documentation

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