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Jurnal Keperawatan Indonesia
Articles
VIEWS: 1577
10.7454/jki.v25i1.1139
Submitted: 2023-01-26
Published: 2022-03-31

Nursing Documentation in Accredited Hospital

Faculty of Nursing Universitas Jember, East Java 68121
Faculty of Nursing Universitas Jember, East Java 68121
Faculty of Nursing Universitas Jember, East Java 68121
accreditation hospital nursing care nursing documentation

Abstract

Nursing documentation is assessed in hospital accreditation because it includes the actions taken and the quality of provided care. Hospital accreditation undergoes three phases consist of preparation, implementation, and post-accreditation. In the post-accreditation phase, there is reduced compliance of workers and nurses. This study determines the quality of nursing documentation at the fully accredited hospital by using descriptive and quantitative research with a retrospective approach. A simple random sampling method is used to attain 292 documents. Data are collected using the Evaluation of Nursing Care Instrument by the Ministry of Health Republic of Indonesia. Results show that nursing documentation has poor quality with an average achievement of 80.81%. In terms of components, the implementation is the most complete whereas the intervention and nursing care parts are the least filled out. Most of the factual indicators have good quality but other records have poor completion or compliance. Observation indicators for documentation quality need review to determine the factors that influence the decline in quality. Hospitals need to review and improve nursing documentation to prevent quality deterioration in the post-accreditation survey. Using information technology for documentation can help nurses because the standardized language and linked systems facilitate documentation of the entire care process, and thus enhance its completeness.

 

Abstrak

Dokumentasi Asuhan Keperawatan pada Rumah Sakit Terakreditasi. Dokumentasi asuhan keperawatan dinilai dalam akreditasi rumah sakit karena berisi seluruh tindakan keperawatan dan mencerminkan kualitas asuhan keperawatan yang diberikan. Akreditasi rumah sakit terdiri atas tiga fase yaitu fase persiapan, implementasi, dan pasca akreditasi. Pada tahap pasca akreditasi, biasanya terjadi penurunan kualitas pelayanan. Penelitian ini menelusuri kualitas dokumentasi asuhan keperawatan di Rumah Sakit X yang terakreditasi paripurna dengan menggunakan desain deskriptif kuantitatif melalui pendekatan retrospektif. Sebanyak 292 sampel dokumen diperoleh dengan teknik simple random sampling. Data dikumpulkan dengan menggunakan Instrumen Evaluasi Asuhan Keperawatan oleh Departemen Kesehatan Republik Indonesia. Hasil penelitian menunjukkan kualitas dokumentasi keperawatan tidak baik, dengan pencapaian rata-rata 80,81%. Komponen implementasi merupakan yang paling banyak terisi, sedangkan intervensi dan catatan asuhan keperawatan paling sedikit terisi. Sebagian besar indikator faktual memiliki kualitas yang baik, tetapi catatan lain memiliki kelengkapan yang buruk. Indikator observasi kualitas dokumentasi perlu dikaji ulang untuk mengetahui faktor-faktor yang memengaruhi penurunan kualitas dokumentasi keperawatan. Rumah sakit perlu meninjau dan meningkatkan dokumentasi keperawatan untuk mencegah penurunan kualitas dalam survei pasca akreditasi. Penggunaan teknologi informasi untuk dokumentasi dapat membantu perawat karena adanya standarisasi bahasa dan sistem yang saling terkait memfasilitasi dokumentasi seluruh proses perawatan, dan dengan demikian meningkatkan kelengkapannya.

Kata Kunci: akreditasi, asuhan keperawatan, dokumentasi keperawatan, rumah sakit

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How to Cite

Purwandari, R., Kurniawan, D. E., & Kotimah, S. K. (2022). Nursing Documentation in Accredited Hospital. Jurnal Keperawatan Indonesia, 25(1), 42–51. https://doi.org/10.7454/jki.v25i1.1139