Gambaran kelengkapan dokumentasi pengkajian awal pasien rawat inap lantai 2 di paviliun rumah sakit umum siloam = description of completeness inpatient initial assessment floor 2 in pavilion general hospital siloam

Budyanto, Budyanto (2018) Gambaran kelengkapan dokumentasi pengkajian awal pasien rawat inap lantai 2 di paviliun rumah sakit umum siloam = description of completeness inpatient initial assessment floor 2 in pavilion general hospital siloam. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Documentation is a continuous activity to assess the quality of nursing services performed by nurses directly to improve the quality of service. One of the factors influencing the implementation of documenting nursing care (assessment, diagnosis, intervention, implementation and evaluation). In doing documentation many studies show that nursing documentation in various hospitals still has not reached the standard so that the error in documenting the patient. This study aims to determine the description of the completeness of the initial assessment documentation of inpatients on 2nd floor in the pavilion of Siloam Lippo Karawaci General Hospital. This research is a quantitative research using descriptive method with cross sectional approach. The sampling technique is done by using purposive sampling. The instrument of this study using documentation study that has been modified by researchers. Samples at RSUS 2nd floor inpatient room received 48 samples of medical record document with 100% result and found there were 6 points below 80% value ie P7 (71%), P8 (62%), P15 (8%), P16 (50 %), P27 (69%), P28 (50%). Researchers suggest for hospital institutions, especially nurses in order to maintain data collection in accordance with SOP and pay attention to the completeness of patient documentation / Dokumentasi merupakan suatu kegiatan berkesinambungan untuk menilai mutu pelayanan keperawatan yang dilakukan oleh perawat secara langsung untuk memperbaiki mutu pelayanan. Salah satu faktor yang mempengaruhi pelaksanaan pendokumentasian asuhan keperawatan (pengkajian, diagnosa, intervensi, implementasi dan evaluasi). Dalam melakukan dokumentasi banyak penelitian menunjukkan bahwa dokumentasi keperawatan di berbagai rumah sakit masih belum mencapai standar sehingga terjadinya kesalahan dalam melakukan pendokumentasian terhadap pasien. Penelitian ini bertujuan untuk mengetahui gambaran kelengkapan dokumentasi pengkajian awal terhadap pasien rawat inap lantai 2 di paviliun Rumah Sakit Umum Siloam Lippo Karawaci. Penelitian ini merupakan penelitian kuantitatif dengan menggunakan metode deskriptif dengan pendekatan cross sectional. Teknik pengambilan sampel dilakukan dengan menggunakan purposive sampling. Instrumen penelitian ini menggunakan studi dokumentasi yang sudah dimodifikasi oleh peneliti. Sampel pada ruang rawat inap lantai 2 RSUS di dapatkan 48 sampel dokumen rekam medis dengan hasil 100% dan ditemukan ada 6 poin dibawah nilai 80% yaitu P7(71%), P8(62%), P15(8%), P16(50%), P27(69%), P28(50%). Peneliti menyarankan untuk institusi rumah sakit khususnya perawat agar dapat mempertahankan pendataan sesuai dengan SOP dan memperhatikan kelengkapan dokumentasi pasien.

Item Type: Thesis (Bachelor)
Creators:
CreatorsNIMEmail
Budyanto, BudyantoUNSPECIFIEDUNSPECIFIED
Contributors:
ContributionContributorsNIDN/NIDKEmail
Thesis advisorSiswadi, YakobusUNSPECIFIEDUNSPECIFIED
Thesis advisorTahapary, PriscaUNSPECIFIEDUNSPECIFIED
Uncontrolled Keywords: Dokumentasi; Pengkajian awal; Dokumentasi Keperawatan; Documentation; Preliminary Assessment; Nursing Documentation
Subjects: R Medicine > RT Nursing
Divisions: University Subject > Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing
Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing
Depositing User: Users 13 not found.
Date Deposited: 15 Jul 2019 05:14
Last Modified: 20 Jul 2020 02:45
URI: http://repository.uph.edu/id/eprint/4005

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