Deskripsi kelengkapan dokumentasi pengkajian awal keperawatan lantai 6a medical paviliun umum rumah sakit siloam / description of early nursing assessment documentation completion at medical 6a floor pavilion general hospital siloam.

Gultom, Helma Uliana (2018) Deskripsi kelengkapan dokumentasi pengkajian awal keperawatan lantai 6a medical paviliun umum rumah sakit siloam / description of early nursing assessment documentation completion at medical 6a floor pavilion general hospital siloam. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Nursing documentation consists of five stages including assessment, diagnosis, planning, implementation and evaluation. Assessment is the first step of the nursing process. The implementation of the assessment includes vital signs, nutrition status, functional activities, mental status, psycho – social – economic – spiritual, communication and education needs as well as nursing issues. Providing appropriate nursing care to clients will avoid errors and unaccountability. The purpose of this study is to describe the completion of the documentation in regard with the early nursing assessment at medical 6a floor Pavilion General Hospital Siloam. This study applied a quantitative observation study using random sampling. The instrument of this study was a check list using by the Siloam Hospital. The study population was an average of 277 per month of the early nursing assessment documents, with a sample of 161 documents. Documentation analysis was applied in this study. The result showed that most of the documents were complete (65.83%). It is concluded that though most of the early nursing assessment was complete, more than a quarter of the documents were incomplete. Therefore, it is noted that the Siloam Hospitals should pay attention more regarding these documentation issues / Pendokumentasian keperawatan terdiri dari lima tahapan yaitu pengkajian, diagnosis, perencanaan, pelaksanaan dan evaluasi. Pengkajian adalah langkah awal dari proses keperawatan. Pelaksanaan pengkajian meliputi tanda- tanda vital, nutrisi, aktivitas fungsional, status mental, psiko- sosial- ekonomi- spiritual, kebutuhan komunikasi dan edukasi dan masalah keperawatan. Pemberian asuhan keperawatan yang tepat kepada klien akan menghindari kesalahan dan dari tindak gugat. Tujuan dari penelitian ini adalah mendeskripsikan kelengkapan dokumentasi pengkajian awal keperawatan lantai 6a medical Paviliun Umum Rumah Sakit Siloam. Penelitian ini akan menggambarkan seberapa lengkap pengkajian awal keperawatan yang sudah dilakukan. Teknik penentuan sampel menggunakan random sampling. Instrumen yang digunakan adalah daftar check list lengkap dan tidak lengkap pengkajian awal yang di gunakan oleh Rumah Sakit Siloam berdasarkan observasi peneliti. Populasi penelitian ini 277 lembar pengkajian awal keperawatan yang sudah terisi, dengan target sampel sebanyak 161 lembar pengkajian awal. Metode yang digunakan adalah studi dokumentasi dan analisis penelitian ini menggunakan deskriptif kuantitatif. Hasil penelitian diperoleh bahwa (65,83%) dokumen yang dilengkapi. Kesimpulan perawat di ruang lantai 6a medical tidak mengisi lengkap pengkajian awal keperawatan saat di ruangan. Saran bagi rumah sakit adalah memperhatikan kinerja perawat saat diruangan.

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