Savitri, Agatha Kientan and Noya, Herlin (2018) Gambaran kelengkapan pendokumentasian pengkajian keperawatan di satu rumah sakit swasta di Indonesia tengah = description of completeness of documentation of nursing assessment in a private hospital in central Indonesia. Bachelor thesis, Universitas Pelita Harapan.
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Abstract
Dokumentasi adalah bentuk dari catatan klinis kondisi pasien serta sebagai bentuk tanggung jawab dan tanggung gugat bagi perawat profesional. Insiden ketikdaklengkapan dokumentasi dapat memunculkan kesalahan dalam komunikasi, perencanaan tindakan, dan pengambilan tindakan yang dapat menurunkan mutu asuhan keperawatan. Tujuan penelitian ini untuk mengetahui kelengkapan pengkajian keperawatan di salah satu rumah sakit swasta di Indonesia Tengah. Pengambilan data menggunakan lembar observasi. Desain yang digunakan yaitu kuantitatif deskriptif. Populasi yang akan digunakan ialah seluruh pasien rawat jalan dari bulan Desember 2017 hingga Mei 2018 dengan populasi yaitu 5955 sehingga sampel digunakan sebanyak 597. Pemilihan sampel menggunakan random sampling. Berdasarkan penelitian yang dilakukan, ditemukan bahwa 93% data tidak lengkap sedang 7% dinyatakan lengkap. Hal ini menunjukan bahwa pengimplementasian standar operasional prosedur tidak dilakukan secara tidak lengkap. Selain itu, pertanyaan yang paling sering tidak diisi atau dikaji secara lengkap adalah pertanyaan mengenai nilai-nilai budaya dan kepercayaan dengan persentase sebesar 83%. Sehingga perlu adanya peningkatan pengawasan agar dokumentasi dapat dilakukan secara lengkap. Serta perlu sosialisasi agar meningkatkan pengetahuan perawat = It is very important for nurse to comply with documentating procedure of nursing care, otherwise there will be incomplete and non-authentic medical record. If this incident happend can lead to miss-communication, and bad patient handling. The purpose of this reserach is to knowing completeness of nursing assessment in a privat hospitals in the middle part of Indonesia. The data will be evaluated by observation paper. Population of the research is outpatient records registered from December 2017- May 2018 that is about 5955 document. Therefore, the sample that will be using is about 597 document. Sample is randomly determined. The obtained data will accordingly be analyzed with quantitative descriptive method. Based on the research found that 93% documents are recorded incomplete and about 7% documents determined complete. This incomplete documents run through all component of nursing assesment. The biggest incomplete documentation were on cultural values and faith assessment with the research result is 83%. This result show that hospitals regulation hasn’t doing well. Therefore, the hospitals managements need to improve their supervision and do socialization, so the nurses can improve their knowledge and effectivity.
Item Type: | Thesis (Bachelor) | ||||||||||||
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Uncontrolled Keywords: | Kelengkapan; Pengkajian; Rekam Medis; Assessment; Completeness; Medical Record | ||||||||||||
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 |
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Depositing User: | Users 13 not found. | ||||||||||||
Date Deposited: | 13 May 2019 00:49 | ||||||||||||
Last Modified: | 27 Jul 2020 00:27 | ||||||||||||
URI: | http://repository.uph.edu/id/eprint/3073 |
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