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.