Pengalaman Perawat dalam Melakukan Dokumentasi Asuhan Keperawatan di Rumah Sakit.

Abstract

ABSTRACT Documentation of care in nursing is part of the activities that the nurse must perform after providing nursing care to the patient containing all the information needed to determine the assessment, diagnosis, intervention, implementation, and evaluate nursing actions that are systematically, validly and responsibly morally and lawfully. Documentation of nursing care consists of 5 components, namely: assessment, diagnosis, planning, implementation and evaluation. Documentation of nursing care both written manually and computerized done to record the services provided or as an information tool to other health workers. The purpose of this study is to know the experience of nurses in doing nursing sisters documentation in the hospital. The type of research used is qualitative. The number of 10 participants selected based on purposive sampling technique and data retrieval is done by in-depth interview technique. The results of the research have been conducted there are several themes related to the nurse's perception about the implementation of nursing documentation, obstacles in doing nursing care documentation, efforts in improving the documentation of nursing care, the benefits of experience in doing nursing care documentation. The conclusion of this research is nurse experience in doing nursing care documentation can not be separated from nurses' knowledge and compliance. Knowledge and compliance will affect the quality of nursing care documentation. It is expected that nurses pay attention to standards and regulations regarding nursing care documentation of the hospital. Keywords: nursing care documentation, nursing experience References: