Rozawati, Desi and situmorang, Elisda (2025) Hubungan pengetahuan perawat dengan kepatuhan pendokumentasian asuhan keperawatan pada sistem emr =Elecronic medical record. Bachelor thesis, Universitas Pelita Harapan.
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Abstract
Latar Belakang : Kelengkapan dokumentasi memengaruhi kualitas dan ketepatan informasi serta mengurangi kemungkinan kesalahan dalam proses dokumentasi asuhan keperawatan. Rumah Sakit Siloam Jambi telah menerapkan sistem pendokumentasian berbasis Electronic Medical Record (EMR). Namun, ditemukan ketidaksesuaian antara implementasi keperawatan yang telah dilakukan
oleh perawat dengan pendokumentasian asuhan keperawatan. Selain itu, terdapat perubahan signifikan dari sistem berbasis kertas (paper- based) ke sistem berbasis
elektronik (electronic-based), serta pemahaman yang masih kurang tentang pengisian formulir pada EMR. Kelengkapan pendokumentasian yang belum
optimal, dengan target minimal 98-100%, menjadi perhatian utama. Hingga saat ini, belum dilakukan evaluasi terkait hubungan antara pengetahuan perawat
dengan kepatuhan dalam pendokumentasian menggunakan EMR di Rumah Sakit Siloam Jambi. Tujuan: Penelitian bertujuan untuk mengidentifikasi hubungan
antara pengetahuan perawat dengan kepatuhan pendokumentasian asuhan keperawatan pada EMR. Metode: Penelitian ini menggunakan desain kuantitatif
korelasional dengan pendekatan cross-sectional. Populasi penelitian ini adalah perawat yang bekerja di ruang rawat inap dan rawat jalan di Rumah Sakit Siloam Jambi, berjumlah 97 perawat, dengan teknik pengumpulan sampling adalah total sampling. Analisis data dilakukan menggunakan yaitu univariat dan bivariat dengan analisa uji chi- square. Hasil: Berdasarkan uji Chi-Square diperoleh (p value = 0.995) lebih besar dari (p value 0.005) yang menyatakan tidak adanya hubungan antara pengetahuan dengan kepatuhan dalam pendokumentasian asuhan
keperawatan. Saran : Diharapkan pihak rumah sakit dapat memfasilitasi perawat dengan diadakan pelatihan,seminar,supervisi,reward dan meningkatkan sarana prasarana untuk pemenuhan dan peningkatan pelayanan di rumah sakit/Background: Completeness of documentation affects the quality and accuracy
of information and reduces the possibility of errors in the nursing care
documentation process. Siloam Jambi Hospital has implemented an Electronic
Medical Record (EMR)-based documentation system. However, there was a
discrepancy between the implementation of nursing that had been carried out by
nurses and the documentation of nursing care. In addition, there was a significant
change from a paper-based system to an electronic-based system, as well as a
lack of understanding about filling out forms on the EMR. The completeness of
documentation that is not optimal, with a minimum target of 98-100%, is a major
concern. Until now, there has been no evaluation regarding the relationship
between nurses' knowledge and compliance in documentation using EMR at
Siloam Jambi Hospital. Objective: The study aims to identify the relationship
between nurses' knowledge and compliance in documenting nursing care in EMR.
Method: This study used a quantitative correlational design with a cross-sectional
approach. The population of this study were nurses working in inpatient and
outpatient rooms at Siloam Jambi Hospital, totaling 97 nurses, with a total
sampling technique. Data analysis was carried out using univariate and bivariate
with chi-square test analysis. Results: Based on the Chi-Square test, it was
obtained (p value = 0.995) greater than (p value 0.005) which stated that there
was no relationship between knowledge and compliance in documenting nursing
care. Suggestion: It is expected that the hospital can facilitate nurses by holding
training, seminars, supervision, rewards and improving facilities and
infrastructure to fulfill and improve services in the hospital.
Item Type: | Thesis (Bachelor) |
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Creators: | Creators NIM Email ORCID Rozawati, Desi 01502230044 desirozawati187@gmail.com UNSPECIFIED situmorang, Elisda 01502230045 Elisda.situmorang@gmail.com UNSPECIFIED |
Contributors: | Contribution Contributors NIDN/NIDK Email UNSPECIFIED Hutapea, Adventina UNSPECIFIED adventina.hutapea@uph.edu UNSPECIFIED Zega, windy 20190041 windy.zega@uph.edu |
Uncontrolled Keywords: | dokumentasi keperawatan; eletronic medical record; Kepatuhan;Pengetahuan;Perawat |
Subjects: | R Medicine > R Medicine (General) R Medicine > RT Nursing R Medicine > RZ Other systems of medicine |
Divisions: | University Subject > Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing |
Depositing User: | Desi Rozawati |
Date Deposited: | 08 Jul 2025 06:41 |
Last Modified: | 08 Jul 2025 06:41 |
URI: | http://repository.uph.edu/id/eprint/69093 |