Nursing Care Documentation Research Articles

Implementasi of technology acceptance model (TAM) in electronic documentation of nursing care: phenomenology explorative

Incomplete medical record documentation affects the quality of service in hospitals. The migration of SIMRS is intended to allow hospital services to be integrated. The use of electronic medical records as a nursing care documentation tool needs to be evaluated in terms of the acceptance of technology through three constructs: the effect of benefits, the effect of ease of use of the system, and self-confidence in computing ability. The study aims to explore the nurses’ experiences of the influence of the benefits of using technology, the ease of use of technology, and nurses' self-confidence when using technology. This study used qualitative methodology with an exploratory phenomenological approach. Data were collected through FGDs with 12 participants selected by purposive sampling technique and consultation with information technology and nursing management experts. Data analysis used the Collaizi Model. The results obtained from this study indicate that the electronic care documentation system must consider the security system of the medical record and that obstacles to operating the system must be anticipated. Guidelines should be made for the application of 3S nursing care in EMR. Adapting to technology influences self-confidence in computing ability, the belief that technology can complete tasks, the usefulness of technology, and the ease of use of electronic documentation technology. It can be concluded that the evaluation of technology acceptance as early as possible is very important to support the successful use of information systems and provide input for management and policymakers in understanding the process of adaptation to new technologies and the creation of practical guidelines for the successful implementation of information systems.

Application of Individual Nursing Care Software for Public Health Nurses at the Indramayu District Health Center

Public Health Nursing (Perkesmas) is one of the health centers' efforts that supports the improvement of public health status by integrating nursing knowledge/practice with public health through the support of active community participation. Perkesmas service activities can be carried out inside and outside the Puskesmas building. Nurses provide nursing care for individuals who come to the puskesmas, provide family nursing care and nursing care for special groups/health-prone groups in the Perkesmas target area (home visits to vulnerable families). The problem for partners who are appointed in this community service program is the Documentation of Individual Nursing Care in the Perkesmas program which is less than optimal. This program offers solutions that are expected to help solve partner problems. The method used is to develop an application system in the documentation of individual nursing care in the health care program. As a result of this community service program, partners have an application system that will make it easier for community health workers in documenting individual nursing care in the community health program. The results of this program will also be published in accredited national or international journals.

Paker Digital Application in Making Palliative Nursing Care

Digital documentation as legal ethics in reporting nursing care is a way to save and evaluate the actions taken by nurses. Digital documentation has several advantages rather than manual documentation, including increased communication between nurses, and medical workers as well as the effectiveness of time in making nursing care documentation better. This study aims to create Android-based digital documentation which can be used as a guide in providing palliative nursing care for cancer patients with a focus on physical and social problems. The research design that used in this research was research and development (R&D) with a quantitative approach and ADDIE development model. The trial of this application was conducted on 15 nursing students with a purposive sampling technique. The Blackbox and application eligibility test got an 83 score which showed that this application is categorized as excellent, acceptable, and suitable for use. Documentation is an important part of making nursing care which must be learned and mastered by nurses through lectures. Studying documentation from assessment to evaluation can improve the professional ability of prospective nurses in providing real implementation to patients. This application can be a useful tool for nurses as a medium for learning nursing care documentation.

Nurse’s individual factor may influence quality of nursing documentation in the inpatient room

To analyse the influence of nurses' impact on the quality of documentation in an inpatient setting. The descriptive, correlational, cross-sectional study was conducted at two government hospitals in East Java, Indonesia, from December 2018 to February 2019 after approval from ethics review committee of Universitas Airlangga, Surabaya, Indonesia. The sample comprised nurses regardless of age and gender who had a minimum work experience of 6 months. Individual factors noted were gender, education, age, length of work, knowledge and motivation of the nurses, knowledge and motivation, while the quality of nursing care documentation was the variable dependent. Data was collected using a demographic nurses, knowledge, motivation questionnaire and nursing documentation observation sheet. Of the 150 nurses, 92(61.33%) were females and 58(38.67%) were males. The largest age group was that of early adults 92(61.33%), 46(30.67%) had 1-5 years of work experience, 115(76.67%) had diploma level of education, 81(54%) had less knowledge, and 86(57.33%) had strong motivation. The quality of documentation was in the good category in 74(49.33%) cases, and it had a significant relationship with education (p=0.011), knowledge (p=0.001) and motivation (p=0.001). Good quality of nursing documentation was found to be influenced by education, knowledge and motivation of the nurses.

Perilaku Kontrol yang Dirasakan Perawat dalam Pendokumentasian Asuhan Keperawatan

Background : Nursing documentation is an important aspect of nurse profesionalism. Therefore each nurses should write down their activity properly according their role. However, to keep nurse documenting their prefossional behavior have been challanging according to studies. Objective: This study aims to portray how nurses perceived behavior control toward nursing documentation in hospital. Method: an observational study was conducted to investigate perceived behavior control among nurses working in ward setting. A total sampling technique was applied to recruite 47 nurses work in pediatric ward. Univariate analysis was utilized. Results: Most respondents were female, age 37.9 (7.5) years old on average, with undergraduate in nursing education background. Currently nurses were qualified for the first level of clinical nurse’s career path (PK 1), and working as associate nurses. The average score of nurses’ perceived control behavior over nursing care documentation was 68.59 (5.13). Conclusion: Nurses perceived behaviors control over nursing care documentation were slighty over the mediocre values, Nurses tend to have positive perception on their control over documenting nursing care.

Legal Consistency of Health Personnel in Making Medical Records

Introduction to The Problem: Medical record is a record or document containing patient identity, examination, treatment, action and other services that must be made by health workers, but not 100% complete medical records. Currently, when talking about medical records, doctors always think, while in the law on health workers, medical records must be made by health workers Purpose/Objective Study: to find out the legal certainty of health workers in making medical records Design/Methodology/Approach: This research is normative with deductive research analysis. Findings: the results of patient records carried out by the medical profession are called medical records, patient records carried out by nurses are called nursing care documentation and patient records carried out by midwives are called midwifery care documentation. Doctors who do not make medical records can get criminal sanctions, while nurses and midwives if they do not do documentation of care will get administrative sanctions . Paper Type: Research Article

Beban Kerja Perawat Berhubungan Dengan Kepatuhan Pendokumentasian Asuhan Keperawatan Di IGD RSUD Kota Bogor Tahun 2022

Introduction: Based on the data obtained from January to May 2022 in the Bogor City Hospital Emergency Room, it was found that the documentation of nursing care was not optimal. 7 Emergency Room nurses said that the workload of nurses was quite heavy with countless patient visits with various criteria. Incomplete documentation of nursing care will lead to a decrease in the quality of nursing services and the occurrence of a problem that has the potential to become a legal case for nursing staff. Therefore, it is necessary to increase knowledge regarding the completeness of proper documentation and motivation from leaders and management so that nurses can complete the documentation of nursing care optimally. Methods: This study uses a cross-sectional descriptive quantitative method, with the type of correlation. The samples taken were 42 respondents. The instruments used were the workload questionnaire from Nursalam and the Hospital Nursing Care Standards (SAK) observation sheet. The dependent and independent variables in this study were Compliance with nursing care documentation and nurses’ workload. Results: The age distribution where nurses were mostly early adults with 33 people (78,6%), and the gender of most of them was 29 people (69%), The distribution of nurses' workload is almost entirely moderate, namely 35 people (83,3%) while the distribution of documentation compliance level is mostly obedient, which is 24 people (57,1%). Correlation Test Results p-value was obtained at 0,031 (< 0,05). Discussion: There is a significant relationship between the workload of nurses and the compliance of nurses' documentation in Bogor City Hospital Emergency Room in 2022.

Connection Motivation Work Nurse With Accuracy Charging Documentation Care Nursing at Sundari Hospital Medan

Accuracy in filling out nursing care documentation is important in nursing services, because it will provide legal protection for both the giver and the recipient. Nursing care will reflect the quality of nursing care. The accuracy of filling nursing care documentation is influenced by motivation. From the results of the study the standards of nursing care applied were taken from 30 patient statuses. Can be taken the result of 61.5%. Who performs the standard nursing care that is applied. This study aims to determine the relationship between the work motivation of nurses and the accuracy of documentation of nursing care in the living health care installation at the Sundari Hospital in Medan. This type of research is quantitative descriptive with a cross sectional approach. Samples for the motivation of nurses were taken from 4 living medical care units with a total sample of 30 respondents, and for the accuracy of filling out nursing care documentation, quota sampling was taken. Data was taken using a questionnaire, for the accuracy of filling out nursing care documentation using the ASAK instrument from the Ministry of Health 1997. To determine the relationship between two variables, the Product Moment Correlation Test was carried out with the results of rxy = 0.474 and p = 0.008, which means that there is a significant relationship between nurses' work motivation. with the accuracy of filling out nursing care documentation in the inpatient room at Sundari Hospital Medan.

Knowledge and Attitude of Nurses with Computerized Based Nursing Care Documentation

The completeness of the implementation of nursing care documentation is part of the quality of services in hospitals that are influenced by the knowledge and attitude of nurses. This study aims to identify the relationship between the knowledge and attitudes of nurses with the completeness of computerized-based nursing care documentation. This research is quantitative research with a descriptive correlation design and cross-sectional approach. The research population were a nurse at the inpatient unit and outpatient unit of Hospital X North Jakarta. The samples used were purposive techniques with 121 respondents. Univariate analysis of nurse knowledge obtained fewer knowledge data with 40 respondents (33.1%) knowledge of 10 respondents (8.3%) and good knowledge of 71 respondents (58.7%) for attitudes, nurses had less attitude with 57 respondents (47.1%) and good attitude of 64 respondents (52.9%). The results of bivariate research show that: there is a meaningful relationship between the knowledge and attitude of nurses with the completeness of documenting computerized-based nursing care at Hospital X North Jakarta, namely knowledge (p value= 0.000) and attitude (p-value = 0.000). The advice in this study is the improvement and development of training for nurses in implementing computerized-based nursing care documentation. So that the development of science from nurses on computerized-based documentation can be carried out properly.

The Influence of the Design of Nursing Care Documentation Design SDKI, SLKI, SIKI (3S) in Hospital Management Information Systems on Nurse Satisfaction at Dian Harapan Jayapura Hospital

The Service is required to be part of the hospital in implementing the documentation of nursing care using computerization. Patients in hospitals often feel dissatisfied with services because nurses take too long to search for patient history data and nurses feel dissatisfied in paper-based documentation which makes the workload increase. The purpose of this study was to design a nursing care documentation design in the 2000s SDKI, SLKI, SIKI (3S) in hospital management information systems on nurse satisfaction. The research method used a research and development design as well as descriptive observational cross sectional with a total sampling technique of 74 nursing respondents at Dian Harapan Jayapura Hospital and analyzed using simple regression analysis. The results showed that 73% of the 3-S nursing care documentation design in SIMRS was in the good category and 77% of nurses were satisfied with the 2000s nursing care documentation design in SIMRS and a significant p-value (0.000) which means that there is an effect of 30.8 % between the design of the 3S nursing care documentation in SIMRS and the satisfaction of nurses at Dian Harapan Jayapura Hospital. It can be said that by increasing the resulting information system, the satisfaction of nurses as users is getting better. It is recommended to hold socialization, training and policy realization for nurses documenting 3S nursing care in SIMRS.

APLIKASI SOFTWARE ASUHAN KEPERAWATAN INDIVIDU BAGI PERAWAT PERKESMAS DI PUSKESMAS WILAYAH KABUPATEN INDRAMAYU

Public Health Nursing (Perkesmas) is one of the health centers' efforts that supports the improvement of public health status by integrating nursing knowledge/practice with public health through the support of active community participation. Perkesmas service activities can be carried out inside and outside the Puskesmas building. Nurses provide nursing care for individuals who come to the puskesmas, provide family nursing care and nursing care for special groups/health-prone groups in the Perkesmas target area (home visits to vulnerable families).
 The problem for partners who are appointed in this community service program is the Documentation of Individual Nursing Care in the Perkesmas program which is less than optimal.
 This program offers solutions that are expected to help solve partner problems. The method used is to develop an application system in the documentation of individual nursing care in the health care program.
 As a result of this community service program, partners have an application system that will make it easier for community health workers in documenting individual nursing care in the community health program. The results of this program will also be published in accredited national or international journals.
 

Hubungan Supervisi Keperawatan dengan Kualitas Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap Kemuning dan Dahlia Rsud Waled Kabupaten Cirebon

Supervision is part of the direction of the management function so that all activities are carried out through information obtained by each staff. The implementation of supervision is carried out by supervisors to improve the quality of care by providing guidance, direction, teaching, motivating and improving nursing care in accordance with standard provisions. The purpose of this study aims to determine the relationship between nursing supervision and the quality of nursing documentation of inpatient wards. Kemuning and Dahlia Hospital Waled Cirebon Regency. The research method used was descriptive correlation with a cross sectional approach. The sample of this study was the executive nurse in the inpatient room Dahlia and Kemuning Waled Hospital Cirebon totaling 33 respondents using purposeful sampling technique. The tools used were questionnaires and observation tables, and the data were analyzed using the chi-square test. The results of the study showed that nursing supervision was good 57.6% and the quality of documentation was also good 60.6% after the statistical test resulted in a p value of 0.031 0.05 which showed a significant relationship between nursing supervision inpatient Kemuning and Dahlia Waled Hospital Cirebon district. Implementing and improving supervision activities can make nurses feel that someone is accompanying them, and this will also have a positive impact on the work of nurses on the quality of nursing care documentation.

Pengembangan Aplikasi Standar Keperawatan Pada Asuhan Keperawatan Anak Di RSUD Indramayu

The Regional General Hospital (RSUD) Indramayu has not implemented the Hospital ManagementInformation System optimally, and also for nursing diagnoses, nursing outcomes, nursinginterventions according to nursing standards have not been included in the system. So that thecommunication and documentation of nursing care that is carried out is still different between fellownurses. In 2021, community service has been held in the form of Application of Standard NursingCare for Medical Surgical Nursing Care at Indramayu Hospital and with this applicationcommunication and documentation of medical surgical nursing care are uniform. So that theIndramayu Hospital asked the Indramayu State Polytechnic to continue community service at theIndramayu Hospital in the pediatric nursing section. The method of implementing communityservice consists of several stages, including: identification of problems and needs, analysis andplanning, system creation, testing and evaluation, and reporting the results of the implementationof service. This community service partnering with RSUD Indramayu produces android-basedapplications and web-based applications and is centered on the server. This application containsthree standard nursing books, namely SDKI, SLKI and SIKI. This application also links the SDKIbook with the SLKI book and links the SDKI book with the SIKI book. The conclusion of communityservice regarding the development of making the application of pediatric nursing standards is the realization of the development of standard nursing applications consisting of an android platformand a website platform, so that the communication of child nursing care becomes uniform.Recording and documentation of uniform pediatric nursing care

TRAINING OF GROUP MODEL CLINIC SUPERVISION IN DOCUMENTATION OF NURSING CARE AT SANSANI HOSPITAL, PEKANBARU

Documentation of nursing care is the responsibility of nurses in improving the quality of nursing services. Nursing documentation is an indicator of quality in assessing the quality of services provided by nurses. Good supervision can improve the competence and performance of nurses in the room. Supervision is a manager's professional support in providing assistance and direction to nursing staff to develop their abilities and competencies of nursing staff. Sansani Hospital in documenting care has made a policy that the application of nursing care documentation is according to standards, but the implementation is still not up to standard. The implementation of supervision in the documentation by the supervisor has not been optimal. Therefore, the IbM team will conduct clinical supervision training for the model group in documenting nursing care. IbM is carried out for 1 year, while the targets in this IbM are the head of the room and the team leader at Sansani Hospital. The solutions offered are socialization of clinical supervision and documentation of nursing care and simulation of the implementation of group model clinical supervision. IbM's output target is clinical supervision training on a group model in nursing care documentation developed in the form of modules and publications in online media. After the training, it was found that there was an increase in knowledge about the supervision of the model group in the documentation of nursing care.

HUBUNGAN PENGETAHUAN DENGAN KELENGKAPAN PENGISIAN DOKUMENTASI ASUHAN KEPERAWATAN BERDASARKAN PENDEKATAN PROSES KEPERAWATAN MAHASISWA KEPERAWATAN SEMESTER VI STIKES BUANA HUSADA PONOROGO

Knowledge is the process of finding information obtained by a person through various sensory organs. Knowledge in this case relates to the completeness of the nursing care documentation. The nursing process as a tool for nurses to carry out nursing care carried out on patients has an important meaning for both parties, namely nurses and clients. The purpose of this study is to analyze knowledge with completeness of filling in nursing care documentation based on the approach of the nursing process of nursing students in semester VI of STIKES Buana Husada Ponorogo. This study used a correlational design . The population in this study was all nursing students in semester VI of STIKES Buana Husada Ponorogo. The sample in this study was all 15 nursing students in semester VI of STIKES Buana Husada Ponorogo. The sampling technique is Total sampling. This study used the Spearman Rank statistical test with α = 0.05. The results of research from 15 respondents showed that student knowledge about nursing care documentation based on the nursing process approach was mostly good as many as 9 respondents (60%), students in documenting nursing care with the nursing process approach were mostly complete as many as 8 respondents (53.3%). There is a Relationship between Knowledge and Completeness of Filling in Nursing Care Documentation Based on the Nursing Process Approach of Nursing Students in Semester VI STIKES Buana Husada Ponorogo.with p value = 0.000 with α = 0.05 Respondents always update the latest science related to nursing care in order to be able to compile nursing care in a comprehensive and orderly manner in accordance with the development of science.

Optimalisasi Penyusunan Dokumentasi Asuhan Keperawatan bagi Perawat Kalimantan Barat

Nursing is a profession for health workers to maintain the quality of health services. The nursing profession makes efforts to develop professional service quality, one of which is regarding nursing care standards, namely documentation. Quality documentation is handy for hospitals in increasing accreditation, communication between professions, indicators of quality services, and a research facility. Nursing documentation, one of them is that diagnosis is an essential aspect of nursing practice. Standard Diagnosis Keperawatan Indonesia, Standart Luaran Keperawatan Indonesia, and Standard Intervensi Keperawatan Indonesia have been compiled by the PPNI professional organization and are expected to improve the quality of Indonesian nursing care documentation. Therefore, there is a need for comprehensive socialization for nurses; the activities carried out were attended by 210 nurses and conducted virtually through zoom meetings. During the activity, pretest and posttest were carried out to determine participants' level of knowledge about SDKI. From the results of the tabulation of participants, it was found that most of the participants were educated professional nurses (70%) and primary nurses (51.90%). The results of the analysis of the results of the pretest-posttest obtained a p-value = 0.000, which indicates a significant difference in nurses' knowledge. The results of this pretest-posttest show that nurses' knowledge can be increased by providing socialization of nursing diagnosis standards. It is expected that hospitals can routinely provide knowledge stimulation, especially about nursing care documentation.

Nurse’s Viewpoint of Gatekeeper Function on Managing Indonesian National Health Insurance: A Qualitatif Study

WHO initiated a policy related to the health for all principles and realized it in the application of gatekeeper theory for increasing the quality of public health center services which include the aspects of First Contact, Continuity, Comprehensiveness, and Coordination services. The purpose of this research was to explore nurses’ perceptions of gatekeepers’ role in NhI services at Public Health Center. This research is using descriptive qualitative design and purposive sampling with thematic analysis is used as sampling technique. Characteristics of the participants include 80% female with qualification 80% are vocational nurses and 60% nurses on duty at community public health center. Results of this research found three major themes including the involvement of administrative services, service providers, and service strategy implementers. The three themes are a manifestation of the integration of implementation of the four main gatekeeper functions by nursing staff of Public Health Center. Services run by nurses are considered less than optimal in first contact and continuous aspect, in term of nursing care documentation and the absence of HIV/AIDS treatment services. This research is expected to be a guide for updating information related to the role of nurses in public health center as gatekeeper.
 
 Keywords: NhI, gatekeeper, nurses, public health center, qualitative

Optimalisasi Tele-Supervisi dalam Pendokumentasian Asuhan Keperawatan di Ruang Rawat Inap Rumah Sakit: Suatu Program Inovasi

This study aims to encourage and improve the quality of nursing care through an innovation program in optimizing supervision in the documentation of nursing care. The method used is an innovation program with a pilot study through a problem solving approach. The innovation program was carried out on the head of the room and team leader who were recruited through purposive sampling using questionnaires, observation sheets and interviews. The results showed that: 1) the problem identification stage, need improvement in the quality of nursing care documentation; 2) the implementation stage, it is necessary to develop a nursing care guide, a checklist form for the quality of documentation, socialization, mentoring and testing of Tele-Supervision; 3) the evaluation stage, the results of the supervision of the documentation of nursing care have been carried out perfectly and completely by the implementing nurse through a trial of the Tele-Supervision form. In conclusion, improving the quality of nursing care documentation needs to be controlled with the implementation of scheduled supervision by the head of the room.
 Keywords: Nursing Care, Nursing Documentation, Innovation, Tele-Supervision

Hubungan Pengetahuan Perawat Tentang Proses Keperawatan Dengan Pendokumentasian Asuhan Keperawatan Di Ruang Rawat Inap RSUD Majalaya

Nursing care are an integral part of health care. The task of the nurse in providing nursing care, among others, assess the needs of patients, nursing action plan, implement the plan of action, evaluate the results of nursing care given and documenting nursing care. The low quality of the completeness of the documentation of nursing care becomes one of the problems in government and private hospitals. Preliminary studies in Majalaya hospital show documentation of nursing care has not been standardized. Documentation of nursing care is an essential element in the accountability of nurses. Documentation must be in accordance with the nursing process. This research was conducted in the inpatient Majalaya hospital in June-August 2022. This study is a descriptive correlation with cross-sectional design. The population was a nurse working in the hospital inpatient Majalaya. Sampling technique was the total number of sampling with 48 nurses. The research instrument used questionnaires to assess nurses' knowledge of the nursing process and observation sheets to determine the completeness of the documentation of nursing care. The results showed the majority of respondents (72.9%) good knowledge of the nursing process, nearly half of respondents (27.1%) knowledgeable enough, and none (0%) less knowledgeable. Documents nursing care the majority (52.1%) filled completely only 47.9% were incomplete. The results obtained Kendalltau bivariate analysis with correlation coefficient 0.635 with a significance level of 0.002 <α (0.05) thus concluded that there is a significant relationship between nurses' knowledge of the nursing process with documentation of nursing care. It is recommended that the training hospitals Majalaya conduct education and training on the nursing process, as well as continuous supervision of at least 3 months by the head of the room in order to improve the implementation of nursing care documentation

Utilization of the SIMPACA Application to improve the quality of nursing care documentation for nurses

The phenomenon of nurses in hospitals being preoccupied with recording documentation activities manually compared to providing independent nursing care to patients. One of the reasons for improving the behavior of nurses in documenting nursing care is increasing the ability of nurses to do documentation using application assistance to facilitate the work of nurses. This community service activity aims to improve the ability of nurses to document effectively and efficiently. The activity was carried out for two days through a zoom meeting. Previously, at the beginning of the activity, a nurse's ability pre-test was conducted and at the end of the session, another measurement was made for the nurse's ability. Community service activities were carried out with 45 nurses in South Sumatra. During the activity, the participants were very enthusiastic in listening, discussing with resource persons, and doing simulations well. There is an increase in documentation ability before and after the documentation training using SIMPACA is carried out. SIMPACA is proven to be effective in improving nurses' documentation skills and reducing nurses' time in documenting their nursing care to patients. There is a need for further development of SIMPACA because it must adapt to the needs of the hospital.