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Providing health services requires quality resources to produce a good outcome. Thus, human resources should be viewed as assets and even hospital investments. Nurses who are the largest proportion of workforce in health services will contribute to the success of the service if they can perform their duties and functions according to standards. Nurses who have good ability and motivation will contribute to the task of administering hospital health services through nursing services. Conversely, nurses who do not perform nursing care properly and correctly can cause problems in patient care. Therefore, this research was conducted with the aim of looking at the relationship between the abilities, motivation and supervision of nurses on the completeness of nursing care documentation in the Imanuel Hospital Sumba ward. This study used a quantitative observational research design with cross-sectional data collection methods by observing or measuring each research variable once at a time. In this study, the research subjects were nurses at Imanuel General Hospital. Subjects were asked to fill out a questionnaire on ability, motivation and supervision. The scores for each questionnaire item are summed. A total score is 100%, a score of 65% or more is considered good, while a score less than 65 is considered insufficient. Of the 22 nurse respondents who served in the inpatient room of Imanuel Sumba Hospital, whose nursing care was then traced, there were 8 nurses (36.4%) whose complete nursing care was categorized as good, and the remaining 14 people (63.6%) had complete care. nursing is in a poor category. Nurses who have good knowledge 17 (77.3%) and less good 5 (22.7%). Nurses who have good skills are 16 (72.7%) and less good 6 (27.3%). Nurses with good motivation are 5 (22.7%) and less 17 (77.3%). Nurses who stated good supervision were 9 (40.9%) and less 13 (59.1%). There is no significant relationship between knowledge (p value = 0.613) and skills (p value = 0.624) with the completeness of nursing care. There is a significant relationship between motivation (p value = 0.039) and supervision (p value = 0.043) with the completeness of nursing care
Dokumentasi keperawatan merupakan bukti dari pelaksanaan keperawatan yang menggunakan metode proses keperawatan, berisi tentang catatan respon pasien terhadap tindakan medis dan tindakan keperawatan serta merupakan indikator mutu asuhan keperawatan. Agar pelayanan keperawatan berkualitas maka perawat diharapkan dapat menerapkan asuhan keperawatan dengan pendokumentasian yang benar.
Penelitian ini bertujuan untuk menganalisis kelengkapan dokumen asuhan keperawatan terkait dengan faktor individu, faktor organisasi dan faktor psikologis, menggunakan metode kualitatif dengan teknik pengumpulan data observasi dan wawancara mendalam. Observasi memungkinkan peneliti mengamati langsung tantangan perawat dalam melengkapi dokumen pengkajian, diagnosa keperawatan, rencana tindakan, implementasi, evaluasi dan catatan keperawatan.
Hasil penelitian menunjukkan bahwa secara umum pengisisan kelengkapan dokumentasi asuhan keperawatan di rumah sakit Santo Antonio masih di bawah standar Depkes. Perawat sudah menyadari pentingnya pendokumentasian asuhan keperawatan. Kendala yang dihadapi antara lain kurangnya tenaga dan kurangnya fasilitas yang ada seperti petunjuk teknis pengisian dokumentasi asuhan keperawatan. Selain itu, belum pernah dilakukan pelatihan terkait dengan pendokumentasian asuhan keperawatan. Perawat memanfaatkan hasil dokumentasi sebagai materi komunikasi kemajuan kondisi pasien, namun dokter belum memanfaatkan secara maksimal hasil dokumentasi yang dibuat oleh perawat.
Saran dari penelitian ini adalah agar pihak manajemen memenuhi jumlah tenaga, mengadakan pelatihan dan seminar, membuat petunjuk teknis pengisian dokumentasi asuhan keperawatan, menerapkan supervise berjenjang serta membuat lembar catatan pasien yang terintegrasi dari seluruh tenaga kesehatan. Saran untuk Kemenkes adalah mengembangkan peraturan yang memberikan pemisahan yang jelas antara tugas dokter dan tugas perawat.
Nursing documentation is an evidence of the implementation of nursing, using the nursing process method, which is contains the report of the patients’ response to the medical and nursing care also an indicator of the nursing care quality. In order to support the nursing care quality, the nurse should applied itself with proper documentation.
The aim of this research is to analyze the completion of the nursing care document, in relation to the individual, organizational, and psychological factors by using qualitative methods such as observation and in-depth interviews. This study is allow to observed nurses challenges to complete the document, diagnose, treatment planning, implementation, evaluation and medical record.
The study revealed that nursing care document completion in Saint Antonio hospital is still below standard even the nurses realized the importance of documenting nursing care. Challenges were found are the nurses work load, no technical guideline for completing the nursing document, no trainings and no workshops for the nurses. Nurses are going to use the results of the documentation to discuss the progress of patient’s condition, but clinicians do not use it as expected.
The study suggests the management to increase the number of personnel, to held trainings and seminars for nurses, to develop technical guideline for nursing documentation, to implement head nurse’s supervision and also create an integrated record sheet based on various personal’s health. Recommendation for Ministry of Health is to provide regulation of clear duty of nurses and doctors.
Latar belakang Pelayanan kesehatan yang bermutu mempakan salah satu kcbutuhan dasar bagi semua masyarakal. Masyarakat menuntut layanan yang lcbih baik, yaitu suatu layanan yang tidak hanya semala mendapatkan pemeriksaan fisik, tetapi juga suatu Iayanan yang ramah, berkesinambungan dapat diterima dan wajar Serta bermulu. Pengukuran mutu layanan dapat di lakukan secara subyektif mnupun secara obyektiti Pengukuran secara obyektif adalah pengukuran terhadap profesionalisme pelayanan seperti Standard Operating Procedurs. Standard Operating Procedurs adalah Suatu perangkat inslruksil langkah-langkah yang di bakukan untuk menyelesaikan suatu proses kerja rutin tertenlu. Kasus diare merupakan kasus yang paling sering di jumpai di rumah sakit. Penatalaksanaan kasus diare pada anak sangat panting, karena kesalahan pada penanganan, dimana konsentrasi terhadap kebutuhan keseimbangan cairan dan elektrolit dapat berakibat fatal yaitu kemalian. Dalam pengawasan pasien ini perawat dalam menjalankan tugasnya dituntut mtuk dapat menjalankan SOP yang telah di buat dan ditetapkan oleh mmah sakit pcnyedia jasa Iayanan kesehatan. Tujuan: Penelitian yang penulis lakukan bemgjuan untuk menjawab pertanyaan mengenai bagaimana gambaran serta apakah ada monitoring dan evaluasi pelaksanaan SOP wuhan keperawatan anak dengan diana oleh perawat di ruang rawat Rumah Sakit Rawa Lumbu. Metode penelitian: Rancangan penelitian ini adalah kualitatif dan kuantitatif dengan menganalisa data secara retrospektif dan dengan melakukan metode wawancara serta Focus Group Discussion terhadap perawat pclaksana, kepala unit ruangan, kepala bidang pcrawat dan dokter spesialis anak Rumah Sakit Rawa Lumbu. Hasil penelitian: Semua responden mengetahu adanya SOP diare pada anak dan mereka mengemhui bahwa sebagian perawat tidak menjalankan SOP tesebut, hal tersebut tenjadi di karenakan perbandingan jumlah perawat dan jumlah tempat tidur tidak seimbang Sementara itu monitoring dan evaluasi terhadap SOP belum pemah dilakukan. Kesimpulan: SOP muhan keperawatan diare pada anak saat ini sudah baik, tetapi pefawat ada sebagian yang belum memahami SOP tersebut dan belum secara lengkap menempkan SOP asuhan keperawatan diare pada anak di karenakan beban kerja perawai yang tinggi. Hal tersebut disebabkan antara Iain adalah tidak tersedianya alat penunjang kcgiatan pelaksanaan SOP juga tidak seimbangnya perbandingan jumlah perawai dan jumlah tcmpax tidur
Background: High quality health services were one of the basic needs in all communities. Community was urging for better services, services which do not only comprising of physical diagnosis, but also kind, continual, acceptable, appropriate and high quality services. Assessment of services quality could be done by either subjective or objective ways. Objective assessment was assessment of services professionalism such as Standard Operating Procedures (SOP). SOP is an instruction or steps protocol that has to be standardized in order to finish some routine work process. Diarrhea cases were ease which very probable to found in hospital. Management of diarrhea cases in children is very important, because of error in handling, such as in the concentration of electrolyte and fluid balance needs, could causing final consequences, in the end was death. When watching these patients, nurses who doing these jobs were urged to do SOP that have been made and signed by the hospital which supplying health services. Aim: Study which writer done was aimed to answer quwtions about how is the description and is there any monitoring and evaluation of children with diarrhea nursing care SOP implementation by nurses in Rawa Lumbu Hospital treatment room. Researching method: this study was designed using qualitative and quantitative method by analyzing data retrospectively and by doing interview method and Focus Group Discussion with practitioner nurses, head of the room unit, and podiatrist ofllawa Lumbu Hospital. Result of the study: All respondents knew the existence of diarrhea in children SOP and they knew that some nurses were not implementing the SOP caused by comparison of nurses and beds amount was unbalanced. ln the other hand, monitoring and evaluation of SOP were never being done before. Conclusion: Diarrhea in children nursing care SOP were good these time, but there were some nurses who have not understand these SOP and have not completely implementing the Diarrhea in children nursing care SOP because of nurse’s high workloads. This could be caused by such thing as instrument of the SOP implementation were not provided and the unbalanced number of comparison between nurses and beds amount.