Electronic Theses and Dissertation

Dokumentasi asuhan keperawatan memiliki fungsi yang sangat penting sebagai perantara komunikasi antar tenaga kesehatan, peningkatan kualitas mutu rumah sakit dan jika terjadi pelanggaran etik dapat menggunakan dokumen sebagai bukti, tetapi jika perawat tidak melengkapi dokumentasi secara optimal akibatnya akan terjadi kegalalan interpretasi hingga berdampak terhadap tindakan askep.Tujuan dari penelitian ini adalah untuk mengetahui gambaran pendokumentasian asuhan keperawatan di RSP USK. Jenis penelitian ini berupa descriptive dan menerapkan metode cross-sectional study. Populasi yang diteliti sebanyak 242 dokumentasi asuhan keperawatan, dengan jumlah sampel yang didapatkan yaitu 49 sampel. Pemilihan sampel menggunakan teknik accidental sampling. Hasil penelitian yandidapatkan di RSP USK terkait pendokumentasian asuhan keperawatan dikategorikan tidak lengkap sebanyak 47 dokumen (95.9%), hanya 2 dokumen (4.1%) yang lengkap. Diharapkan para perawat meningkatkan pengetahuan dengan melanjutkan pendidikan keperawatan dari D3 keperawatan ke pendidikan S1 Ners yang akan meningkatkan upgrade ketrampilan dan soft skill keperawatan.

Documentation of nursing care plays an important function as an intermediary for communication between health workers, an improvement of the quality of hospital quality and if there is a breach of ethics, the document can be used as evidence, but if any nurse does not complete the documentation optimally the result will be a failure of interpretation which will impact on nursing actions. The purpose of this study was to find out the description of nursing care documentation at Teaching Hospital of Syiah Kuala University. In this descriptive study, a cross-sectional study method was employed. The population studied was 242 documentations of nursing care, with a total sample of 49 samples. Moreover, the selection of the sample used accidental sampling technique. The research results obtained at the Teaching Hospital of Syiah Kuala University regarding the documentation of nursing care were categorized as incomplete including 47 documents (95.9%), only 2 documents (4.1%) were categorized as complete. It is recommended for the nurses in crease their knowledge by continuing their nursing education from Diploma Degree to Bachelor Degree of nursing education which will increase and upgrade their nursing skills as well as soft skills.