Gambaran Kelengkapan Dokumentasi Keperawatan di Puskesmas Cerme Kabupaten Gresik
Abstract
Nurse is one of the medical workforce who provides health services to people
through nursing diagnosis. In its implementation, a nurse has to record or make
documentation for the entire nursing care process. The completeness of the nursing
documentation is one indicator of success in executing the nursing care process.
The purpose of this study is to describe the completeness of nursing documentation
at the Cerme Health Center, Gresik Regency. The research method employed is a
retrospective descriptive research design, with a total sampling of 288 nursing care
documents collected from January to August 2022. The research instrument was a
questionnaire that complied with the Ministry of Health’s standard nursing care
and had been modified with 20 assessments of nursing care documentation.
Findings indicate that the Cerme Health Center in Gresik Regency applied the
Problem Intervention/Implementation Evaluation (PIE) documentation format, and
it obtained an average completeness score of 59.1% for 288 nursing care
documents, with aspects of nursing assessment and implementation having the
highest average completeness, specifically 73.4%. Furthermore, the nursing
diagnostic aspect had a 65% average completeness, the nursing intervention aspect
had a 51.0% average completeness, and the nursing assessment aspect had the
lowest average completeness, specifically 31.3%. The results of this study are still
not optimal. This is due to an assortment of conditions, such as the limited format
of nursing documentation and the relatively small number of nursing staff. As a
result, the Cerme Health Center needs to update the nursing documentation format
and provide the nursing staff with nursing documentation training. This aims to
achieve considerably better nursing documentation results.
Collections
- UT-Faculty of Nursing [1518]