Pelaksanaan Dokumentasi Asuhan Keperawatan Di Ruang Rawat Inap Rumah Sakit X Jakarta: Pilot Study

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Published Mar 16, 2023
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Vol. 8 No. 2 (2020): Dunia Keperawatan: Jurnal Keperawatan dan Kesehatan

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I Wayan Gede Saraswasta
Rr Tutik Sri Hariyati
Umi Fatmawati

Abstract

The quality of nursing documentation demonstrates the accountability of nurses in providing nursing care to
patients. However, the implementation of nursing documentation at hospital X is 58% still below the
standard so that it is necessary to optimize the implementation of nursing documentation. The purpose of this
study is to describe an innovation project to optimize the implementation of nursing documentation. The
method used was a pilot study of 70 nursing documentation. The process starts from problem identification,
problem analysis, plan of action, implementation, and evaluation. The quality of nursing documentation is
measured using a nursing documentation audit instrument. Implementation in the form of guidelines,
standart operational procedure (SOP), socialization, trials, assistance and making video roleplay nursing
documentation. The results of the study showed an increase in the implementation of nursing documentation
by 11.40%. The conclusion is that the implementation of an innovation project can improve the
implementation of nursing documentation. The recommendation is to use a guide, SOP and roleplay videos
as a reference in carrying out nursing documentation.

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How to Cite
1.
Saraswasta IWG, Hariyati RTS, Fatmawati U. Pelaksanaan Dokumentasi Asuhan Keperawatan Di Ruang Rawat Inap Rumah Sakit X Jakarta: Pilot Study. jdk [Internet]. 2023 Mar. 16 [cited 2026 Oct. 3];8(2):199-207. Available from: https://jdk.ulm.ac.id/index.php/jdk/article/view/357

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