Gambaran pelaksanaan pengkajian keperawatan pada pasien baru di rumah sakit siloam dhirga surya medan = description of implementation of nursing in new patients in siloam dhirga surya hospital medan.

Manullang, Kartini Octavia (2018) Gambaran pelaksanaan pengkajian keperawatan pada pasien baru di rumah sakit siloam dhirga surya medan = description of implementation of nursing in new patients in siloam dhirga surya hospital medan. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Latar belakang : Pengkajian merupakan kunci membuat keputusan klinis, mengetahui keadaan pasien, serta masalah pasien (Potter & Perry, 2007). Pentingya perawat melakukan pengkajian keperawatan adalah sebagai sarana untuk meningkatkan komunikasi kepada pasien dan kelangsungan perawatan sehingga dapat meningkatkan efisiensi dan keselamatan pasien. Pengkajian ini sangat penting untuk mendapatkan data-data pasien, sehingga gambaran yang terlihat pada pelaksanaan pengkajian keperawatan pada pasien baru adalah data yang didapatkan bukanlah data fokus seperti : Tidak tahu keluhan pasien saat masuk ruangan, Asuhan Keperawatan terhambat, tidak ada kesinambungan antar sesama perawat dalam melakukan asuhan keperawatan, penilaian akreditasi terhambat, dan mutu asuhan keperawatan akan berkurang. Tujuan : Untuk mengetahui gambaran pelaksanaan dokumentasi pengkajian keperawatan pada pasien baru di Rumah Sakit Siloam Dhirga Surya Medan. Metode : Penelitian ini menggunakan metode penelitian deskriptif kuantitatif dan sudah disetujui oleh The Research Committee Ethic (RCTC). Populasi pada penelitian ini adalah seluruh pasien baru di ruang rawat inap mulai bulan Juli sampai dengan bulan September 2017 yang berjumlah 1285 dokumen dan sampel yang diambil berdasarkan perhitungan rumus Slovin adalah sebanyak 93 dokumen. Teknik pengambilan sampel digunakan adalah purposive sampling. Teknik analisa data yang digunakan adalah analisa univariat. Hasil dari penelitian ini menunjukkan bahwa dari 93 dokumen yang diteliti di Rumah Sakit Siloam Dhirga Surya Medan sejumlah 25 (26.88%) dokumen sangat lengkap, sebanyak 40 (43.01%) dokumen lengkap. Adapun saran bagi bidang pendidikan untuk memperhatikan penelitian penelitian terbaru tentang pelaksanaan keperawatan yang lebih efektif serta menyeluruh, bagi pelayanan kesehatan untuk meningkatkan pelayanan kesehatan khususnya melalui pengkajian awal keperawatan yang lengkap, dan bagi peneliti selanjutnya untuk dapat mencari faktor-faktor yang berpengaruh terhadap kelengkapan dokumentasi formulir pengkajian / Background : Asssesment is the key to making clinical decisions, knowing the patient’s condition, and patient problems. The importance of nurses performing nursing assessment is a means to improve patient communication and continuity of care so as to improve patient efficiency and safety. This assessment is very important to obtain patient data, so that the picture seen in the implementation of nursing assessment in new patients is the data obtained is not data focus such as: do not know patient complaints when entering the room, nursing care is hampered, no continuity among fellow nurses perform nursing care, accreditation assessment is inhibited, and the quality of nursing care is reduced. Purpose : To know the implementation of the documentation for the assessment of nursing on a patient in Siloam Dhirga Surya Hospital Medan. Method : This study is the method of research descriptive the applicability and has been approved by The Research Committee Ethic (RTCT). The population in the study this whole new patients in the inpatient care starting in July to September 2017, 1285 documents and samples are taken based on the calculation of the slovin is as much as 93 documents. The sampling used is purposive sampling. The analysis of data used is the analysis of a univariate. As a result of this research shows that of 93 documents, which at Siloam Dhirga Surya Hospital Medan , a number of 25 (26.88%) the document is complete, as many as 40 (43.01%) the document. The advice for the field of education to pay attention to these studies the latest on the implementation of the nursing more effective and thorough, for health services to improve health services, especially through a study into the nursing, and for researchers then to be able to find the factors affecting the completeness of documentation forms for the assessment.

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