KUALITAS PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUMAH SAKIT : LITERATURE REVIEW

  • Dan Tandi Program Studi Magister Keperawatan Universitas Hasanuddin
  • Syahrul Syahrul Fakultas Keperawatan Universitas Hasanuddin
  • Kadek Ayu Erika Fakultas Keperawatan Universitas Hasanuddin

Abstract

Pendahuluan : Dokumentasi asuhan keperawatan merupakan bukti tertulis asuhan yang diberikan oleh perawat kepada pasien. Dokumentasi asuhan keperawatan yang berkualitas sebagai cerminan dari mutu asuhan keperawatan. Tujuan : Untuk mengetahui kualitas pendokumentasian asuhan keperawatan tentang bagaimana pelaksanaan pendokumentasian asuhan keperawatan dan bagaimana kelengkapan pendokumentasian asuhan keperawatan di rumah sakit. Metode : Pencarian literatur dilakukan dengan 4 database yaitu PubMed, ProQuest, Wiley Online Library dan Google Scholar dengan kata kunci  “nursing documentation”, “quality”, “completeness of documentation” dan “nursing care”. Artikel yang memenuhi kriteria inklusi yaitu artikel dipublikasikan antara tahun 2009 sampai 2019, full text, berbahasa Inggris, kuantitatif. Hasil : 6 artikel dengan klasifikasi pelaksanaan pendokumentasian asuhan keperawatan dan kelengkapan dokumentasi asuhan keperawatan. Simpulan : Kualitas pendokumentasian asuhan keperawatan di rumah sakit masih rendah. Oleh karena itu, untuk meningkatkan kualitas pendokumentasian asuhan keperawatan, maka perlu dilakukan pelatihan, pengembangan kesadaran, pengarahan dan pengendalian,  kontrol berkelanjutan, meningkatkan budaya organisasi, perubahan dokumentasi asuhan keperawatan dari berbasis kertas menuju elektronik,  mengurangi beban kerja perawat dengan menambahkan tenaga keperawatan serta kebijakan insentif dari manajemen rumah sakit.


Kata Kunci : kualitas, dokumentasi, asuhan keperawatan

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References

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Published
2020-11-19
How to Cite
TANDI, Dan; SYAHRUL, Syahrul; ERIKA, Kadek Ayu. KUALITAS PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUMAH SAKIT : LITERATURE REVIEW. Jurnal Ilmu Kesehatan, [S.l.], v. 9, n. 1, p. 12 - 20, nov. 2020. ISSN 2579-7301. Available at: <https://ejurnaladhkdr.com/index.php/jik/article/view/269>. Date accessed: 18 jan. 2021. doi: https://doi.org/10.32831/jik.v9i1.269.
Section
Articles