Analisis Kesesuaian penulisan Masalah Keperawatan pada Bangsal Penyakit Dalam RSUD dr. H. Soewondo Kendal

Abstract

ABSTRACT Tiffani Erlita Sari The Analysis of Nursing Problem Writing Fitness In Internal Ward of RSUD dr. H. Soewondo Kendal xxxv + 53 Pages + 5 Tables + 1 Pictures + 9 Attachments Nursing problems is one of the component to formulating the nursing diagnoses. Part of the problem contains a diagnostic label that states directly the problem that is happening to the client. Nursing problems is the elements of the clinical language of nursing in nursing care that need to be improved in quality.This study aims to analyze the suitability of writing nursing problems written on medical documentation records. The subjects observed were nursing problems written in the medical record and will be analyzed based on diagnostic labels on NANDA (North American Nursing Diagnosis Association) Nursing Diagnosis. This descriptive study with a retrospective approach has a study population consisting of medical record documents of patients in the internal medicine ward of RSUD dr. H. Soewondo Kendal period January-December 2018 with 106 documents of sample. This research was carried out by document analysis. The results of the study found that 53,8% of nursing problems were written according to the labeling of NANDA Nursing Diagnosis and 46,2% of nursing problems were written incorrectly. The conclusion of this study is that the percentage of nursing problems written in accordance with NANDA Nursing Diagnosis is more than those written incorrectly. Future research can explore more about the factors that influence the writing of nursing problems. Keyword : Writing fitness, Nursing problem, Internal ward Bibliography: 36 (2006-2018)