Analisis Faktor-Faktor yang Mempengaruhi Kelengkapan Pendokumentasian Asuhan Keperawatan di Ruang Rawat Inap RSUD Dr. Raden Soedjati Soemodihardjo Kabupaten Grobogan Tahun 2012

Abstract

Universitas Diponegoro Program Pascasarjana Program Magister Ilmu Kesehatan Masyarakat Konsentrasi Administrasi Rumah Sakit 2012 ABSTRAK Samuel Setiawan Analisis Faktor-Faktor yang Mempengaruhi Kelengkapan Pendokumentasian Asuhan Keperawatan di Ruang Rawat Inap RSUD Dr. Raden Soedjati Soemodihardjo Kabupaten Grobogan Tahun 2012 98 halaman + 23 tabel + 4 gambar + 9 lampiran Pendokumentasian asuhan keperawatan sangat penting dilakukan ditinjau dari aspek medikolegal, ekonomi (pembiayaan) maupun klinis perjalanan penyakit pasien. Namun penulisan dokumentasi asuhan keperawatan di RSUD Dr. Raden Soedjati Kab Grobogan sering dijumpai tidak lengkap. Tujuan penelitian ini adalah menganalisis faktor – faktor yang mempengaruhi kelengkapan pendokumentasian asuhan keperawatan di ruang rawat inap RSUD Dr. Raden Soedjati Soemodihardjo Kab Grobogan. Jenis penelitian adalah observasional dengan desain cross sectional menggunakan alat bantu kuesioner. Populasi penelitian adalah seluruh perawat pelaksana di ruang rawat inap RSUD Dr. Raden Soedjati Soemodihardjo Kab Grobogan tahun 2011 sejumlah 110 orang. Responden adalah total populasi. Data yang terkumpul dilakukan analisis univariat dan bivariat. Hasil penelitian menunjukkan bahwa 57,3% responden mempunyai proses penulisan yang baik, 68,2% responden berpendapat bahwa standar dokumentasi baik, 66,4% berpendapat bahwa punishment baik dan 68,2% berpendapat bahwa reward baik. Hasil analisis bivariat menunjukkan bahwa ada hubungan antara faktor proses penulisan, standar, punishment dan reward dengan kelengkapan pendokumentasian asuhan keperawatan. Hasil analisis multivariat menunjukkan adanya pengaruh bersama – sama antara umur (p = 0,038, Exp B = 6,72), faktor proses penulisan (p = 0,0001, Exp B = 11,68), standar (p = 0,014, Exp B = 5,65), punishment (p = 0,010, Exp B = 5,01) dan reward (p = 0,0001, Exp B = 17,12) terhadap kelengkapan pendokumentasian askep. Faktor yang paling berpengaruh adalah reward. Saran yang dapat direkomendasikan dalam penelitian ini adalah Melakukan obeservasi dan revisi terhadap standar dokumentasi askep sesuai dengan kondisi yang terbaru (up to date), tentang prosedur kenaikan pangkat sehingga perawat dapat memahami syarat yang harus dipenuhi, memberikan penghargaan yang berupa pujian baik oleh kepala ruang dan rekan sejawat dapat. Kata Kunci : faktor, kelengkapan, dokumentasi asuhan keperawatan, rawat inap Kepustakaan : 40, 1962 – 2008 Diponegoro University Postgraduate Program Master’s Program in Public Health Majoring in Hospital Administration 2012 ABSTRACT Samuel Setiawan Analysis on Factors Related to the Completeness of Nursing Documentation in Inpatient Unit of RSUD. Dr. Raden Soedjati Soemodihardjo, Grobogan District 98 pages + 23 tables + 4 figures + 9 enclosures Based on the medico legal, economy (funding), or clinical aspects of patient’s disease natural history, documentation of nursing care was very important to be performed. However, documentation writing of nursing care in the district general hospital (RSUD) of Dr. Raden Soedjati Grobogan district was incomplete. The study objective was to analyze factors affecting the completeness of nursing care documentation in the inpatient room of RSUD Dr. Raden Soedjati Soemodihardjo Grobogan district. This was an observational study with cross sectional design and using questionnaire as a supporting tool. Study population was all 110 nurses in the inpatient room of RSUD Dr. Raden Soedjati Soemodihardjo Grobogan district in 2011. Study respondents were all 110 nurses included in the study population (total population). Univariate and bivariate analysis were applied in the data analysis. Results of the study showed that 57.3% of respondents had good writing process; 68.2% of respondents had good opinion on the documentation standard; 66.4% of had an opinion that punishment was good; and 68.2% of respondents had opinion that reward was good. Results of bivariate analysis showed that there was an association between the documentation completeness of nursing care and writing process, standard, punishment, reward factors. Result of a multivariate analysis showed the joint effect among age (p= 0.038, Exp B= 6.72), writing process factor (p= 0.0001, Exp B= 11.68), standard (p= 0.014, Exp B= 5.65), punishment (p= 0.010, Exp B= 5.01), and reward (p= 0.0001, Exp B= 17.12) to the documentation completeness of nursing care. The most affecting factor was reward. Recommended suggestions were to do observation and revision to the nursing care documentation standard according to the up to date condition, to the rank promotion procedure therefore nurses are able to understand the requirements that should be fulfilled; to provide reward in the form of appreciation by the room chief and colleagues. Key words : factor, completeness, nursing care documentation, inpatient Bibliography : 40, 1962-2008