Deskripsi dokumentasi asuhan keperawatan di satu rumah sakit swasta Indonesia bagian tengah = description of nursing care documentation in Indonesia central private hospital.

Benu, Angel Juwita Wulandari and Tendage, Gabriela and Ayunda, Sarah Meika (2018) Deskripsi dokumentasi asuhan keperawatan di satu rumah sakit swasta Indonesia bagian tengah = description of nursing care documentation in Indonesia central private hospital. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Latar Belakang: Pemberian asuhan keperawatan yang terbaik serta dapat dipertanggung jawabkan merupakan tuntutan pada era zaman ini. Dokumentasi keperawatan merupakan sebuah informasi tertulis atau elektronik yang menggambarkan perawatan atau layanan yang diberikan kepada pasien serta untuk alat komunikasi yang baik antara para tenaga kesehatan. Berdasarkan pengamatan obyektif terhadap rekam medis pasien rawat inap di rumah sakit swasta Indonesia bagian tengah, ditemukan adanya ketidaklengkapan dokumentasi. Fenomena yang ditemukan dapat menjadi gambaran dokumentasi asuhan keperawatan. Tujuan: penelitian ini untuk mengetahui gambaran dokumentasi asuhan keperawatan. Metode: penelitian ini menggunakan desain deskriptif kuantitatif, analisa data univariat, populasi berupa rekam medis pasien rawat inap lebih dari tiga hari perawatan, sehingga sampel yang digunakan dalam penelitian ini berjumlah 130 rekam medik. Penarikan sampel menggunakan purpossive sampling Instrumen yang digunakan dalam penelitian berupa lembar observasi checklist milik rumah sakit swasta Indonesia bagian tengah yang telah ditetapkan sesuai standar pendokumentasian asuhan keperawatan. Hasil: penelitian yang didapatkan, masuk dalam kategori sangat baik, yaitu pada bulan Februari 88,5%, Maret 91,5% dan April 87,6%. Saran diharapkan hasil penelitian dapat menjadi evaluasi terhadap pelaksanaan pendokumentsian asuhan keperawatan = Background: Providing the best and most responsible nursing care is a demand in this era. Nursing documentation is written or electronic information that describes the care or services provided to patients and for good communication tools between health workers. Based on objective observations of medical records of hospitalized patients in the central Indonesian private hospital, there was an incomplete documentation The phenomenon found can be a description of nursing care documentation. Objective: This research is to know the overview of the implementation of nursing care documentation. Method: This study using quantitative descriptive design, univariate data analysis, the population is medical record files of hospitalized patients over three days treatment, so the total sample used in this study is 130 medical records. Sample taken using purposive sampling The instrument used in this research is the observation checklist of the Indonesian private hospital in the middle part which has been established according to the standard of documentation of nursing care. Results: The result of the research were included into very good category, the percentations are February 88,5%, March 91,5% and April 87,6%. Suggestions are the research result expected to be an evaluation of the implementation of nursing care documentation.

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