PELAKSANAAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN BERDASARKAN FAKTOR MOTIVASI DAN SUPERVISI PIMPINAN DI RSUD DR.MOEWARDI SURAKARTA DOCUMENTATION IMPLEMENTATION OF NURSING PROCESS BASED ON MOTIVATION AND SUPERVISION BY THE LEADER OF RSUD DR.MOEWARDI SURAKARTA

Abstract

Nurses are forced to give the professional treatment especially in nursing process. When nursing process is appropriate as the standard, it will give guarantee of quality and also to reduce costumers' complaints in RSUD Dr.Mowardi Surakarta. The purpose of this research is to know how was the individual characteristic, nurses' motivation, and the leaders supervision with all the documentation equipment of nursing process in wards of RSUD Dr.Moewardi Surakarta. Observational research is by cross sectional approaching. The research was located in RSUD Dr.Moewardi Surakarta with total respondents are 3 wards leaders and 6 implementer nurses. Source of primary data is taken from the interview and the secondary data is taken by the documents of medical report. Analysis of interview is to describe the result of research. It is used for obtaining factors of responses, which were given by the implementer nurses and the wards leaders. It consists of financial and non-financial motivation variables, supervision, and also nursing process documentation. Results of the interview with 9 respondents show that financial intensify do not suffice enough. 9 respondents said that for non-financial intensify by giving award; job estimation, nurses and leader acceptances are appropriate as the nurses' expectation. While in non-financial intensify by degree increasing, safety and job environment comfort, and also infrastructures are not appropriate as the expectation. Having to do with leader's supervision by instruction, guidance, observation, and evaluation are not routine yet. Results. The results toward comprehensive of nursing process documentation that were taken by medical record's documentation in RSUD Dr.Moewardi show that for incomplete investigation score are 71,14 %, less complete are 21,43 %, and complete are 7,14 %. Incomplete diagnose are 57,14 %, complete are 43,86 %, and incomplete is 0 %. Scoring diagnoses which is less complete 57,14 %, complete 43,86 %, and not complete 0 %. In determine the purpose and the criteria results that the complete score are 50 %, less complete are 50 %, and no one incomplete. In nursing action, complete score are 50 %, less complete are 50 %, and 0 % incomplete. The implementation of nursing action, which is complete is 50 %, less complete is 50 %, and no one incomplete. The evaluation scoring for less complete are 78,57 %, complete are 14,29 %, and incomplete are 7,43 %. Signatures and the name of the nurses that complete are 71,43 %, less complete are 21,43 %, and incomplete are 7,43 %. While in nursing note scoring, which incomplete are 42,86 %, less complete are 35,71 %, and complete are 21,43 %. Nursing resume scoring, which incomplete are 78,57 %, less complete are 21,43 %, and 0 % complete. In returning home note or for the death, which incomplete are 78,57 %, less complete are 21,43 %, and complete is 0 %. Conclusion. The financial intensify do not suffice enough, non-financial intensify as degree increasing, safety and job environment comfort; infrastructures are still less appropriate as the nurses' expectation. And documentation implementations of nursing process in RSUD Dr.Moewardi Surakarta that consist of 10 points are less complete. Suggestion. RSUD Dr.Moewardi Surakarta should increase the effectively of leader's supervision especially in nursing management, increase the entire financial intensify and the appropriate of non-financial intensify with the reality. Dalam memberikan pelayanan kesehatan khususnya asuhan keperawatan, perawat dituntut untuk memberikan pelayanan yang professional. Apabila asuhan keperawatan dilaksanakan sesuai dengan standar asuhan keperawatan, akan dapat memberikan jaminan kualitas serta mengurangi keluhan-keluhan klien di RSUD Dr.Moewardi Surakarta. Tujuan penelitian ini adalah untuk mengetahui karakteristik individu, motivasi perawat, dan supervisi pimpinan dengan kelengkapan pendokumentasian asuhan keperawatan di ruang rawat inap RSUD Dr.Moewardi surakarta. Jenis penelitian observasional dengan pendekatan cross sectional Lokasi penelitian di RSUD Dr.Moewardi Surakarta dengan jumlah responden 3 orang kepala bangsal dan 6 orang perawat pelaksana. Sumber data primer diperoleh melalui wawancara mendalam dan data skunder diambil dari dokumen rekam medis . Analisit wawancara mendalam untuk mendeskripsikan hash penelitian. Analisis ini digunakan untuk memperoleh gambaran faktor-faktor jawaban perawat pelaksana dan kepala bangsal yang meliputi variabel motivasi finansial dan non finansial, supervisi serta pendokumentasian asuhan keperawatan. liasil wawancara dengan 9 responden semuanya menyatakan bahwa insentif finansial dirasa masih kurang mencukupi. Untuk insentif non finansial dari 9 responden menyatakan bahwa insentif non finansial berupa penghargaan, penilaian kerja, penerimaan sesama perawat, dan penerimaan pimpinan sudah sesuai dengan yang diharapak perawat. Sedangkan insentif non finansial berupa kenaikan pangkat, keamanan, kenyamanan lingkungan kerja, dan tersedianya sarana dan prasarana kurang sesuai dengan yang diharapkan. Perihal supervisi pimpinan berupa pengarahan, bimbingan, observasi, dan evaluasi belum dilaksanakan secara rutin. Adapun hasil penelitian terhadap kelengkapan pendokumentasian asuhan keperawatan yang diambil dad dokumen rekam medis rawat inap di RSUD Dr.Moewardi Surakarta menunjukkan bahwa untuk pengkajian nilai tidak lengkap 71,14 %, kurang lengkap 21,43 %, dan lengkap 7,14 %. Diagnosis keperawatan nilai kurang lengkap 57,14 %, lengkap 43,86 %, dan tidak lengkap 0 %. Dalam menentukan tujuan dan kriteria hasil nilai lengkap 50 %, kurang lengkap 50 %, dan tidak lengkap 0 %.Tindakan keperawatan nilai lengkap 50 %, kurang lengkap 50 %, dan tidak lengkap 0 %. Pelaksanaan tindakan keperawatan nilai lengkap 50 %, kurang lengkap 50 %, dan tidak lengkap 0 %. Evaluasi nilai kurang lengkap 78,57 %, lengkap 14,29 %, dan tidak lengkap 7,14 % . Tanda tangan dan nama perawat nilai lengkap 71,43 %, kurang lengkap 21,43 %, dan tidak lengkap 7,43 %. Sedangkan untuk catatan keperawatan nilai tidak lengkap 42,86 %, kurang lengkap 35,71 %, dan lengkap 21,43 %. Resume keperawatan nilai tidak lengkap 78,57 %, kurang lengkap 21,43 %, dan lengkap 0 %. Untuk catatan pulang atau meninggal dunia nilai tidak lengkap 78,57 %, kurang lengkap 21,43 %, dan lengkap 0 %. Kesimpulan, insentif finansial masih dirasa kurang mencukupi, insentif non finansial berupa kenaikan pangkat, keamanan dan kenyamanan Iingkungan kerja, tersedianya sarana dan prasarana masih kurang sesuai harapan perawat, supervisi pimpinan belum efektif. Dan pelaksanaan pendokumentasian asuhan keperawatan di ruang rawat inap RSUD Dr.Moewardi Surakarta yang terdiri dari 10 kajian masih dilaksanakan kurang lengkap. Saran. RSUD Dr.Moewardi Surakarta khususnya Manajemen Keperawatan supaya mengefektifkan supervisi pimpinan, meningkatkan insentif finansial secara keseluruhan dan kesesuaian insentif non finansial dengan kenyataan yang ada.