Rekomendasi Desain Dokumentasi Keperawatan untuk Praktik Keperawatan Mandiri

  • Hasti Primadilla Politeknik Kesehatan Tanjungkarang
  • Fitarina Fitarina Politeknik Kesehatan Tanjungkarang
  • Deni Metri Politeknik Kesehatan Tanjungkarang


This study aims to produce paper-based forms that meet the needs of nurses in home care. The method is development research referring to the concept of the Technology Acceptance Model. The results of the analysis show the nurse's belief in the form: believes and feels its usefulness, thinks and feels the ease of use, has a positive attitude towards the form as evidenced by the appreciation conveyed, socialization and advocacy plans to professional organizations, great interest in using it in practice and actual positive behavior demonstrated by multiplying the forms, applying them in practice and using them at the puskesmas home visits. Practitioners expect improvements in column size, increased nursing care content, and standardization. In conclusion, the forms produced in this study can be accepted by independent practice nurses, are ready to be applied, and can be adapted into electronic systems. Nurses have felt its usefulness and ease of use and have continuously proven its use in practice.


Keywords: Documentation, Forms, Acceptance, Independent Nursing Practice


Adereti, C. S., & Olaogun, A. A. (2019). Use of Electronic and Paper-Based Standardized Nursing Care Plans to Improve Nurses' Documentation Quality in a Nigerian Teaching Hospital. International Journal of Nursing Knowledge, 30(4), 219–227.

Akhu-Zaheya, L., Al-Maaitah, R., & Hani, S. B. (2018). Quality of Nursing Documentation: Paper-Based Health Records Versus Electronic-Based Health Records. Journal of Clinical Nursing, 27(3-4), e578–e589.

Brabers, A. E. M., de Groot, K., & Groenewegen, P. P. (2019). Practice Variation among Home Care Nurses. Primary Health Care Research & Development, 20(May), e136.

De Groot, K., Triemstra, M., Paans, W., & Francke, A. L. (2019). Quality Criteria, Instruments, and Requirements for Nursing Documentation: A Systematic Review of Systematic Reviews. Journal of Advanced Nursing, 75(7), 1379–1393.

Hertzum, M. (2021). Electronic Health Records in Danish Home Care and Nursing Homes: Inadequate Documentation of Care, Medication, and Consent. Applied Clinical Informatics, 12(1), 27–33.

Horntvedt, M. T., Nordsteien, A., Fermann, T., & Severinsson, E. (2018). Strategies for Teaching Evidence-Based Practice in Nursing Education: A Thematic Literature Review. BMC Medical Education, 18(1), 172.

Istifada, R., Sukihananto, S., & Laagu, M. A. (2017). Pemanfaatan Teknologi Telehealth pada Perawat di Layanan Homecare. Nursing Current, 5(1), 51–61.

Kamil, H., Rachmah, R., & Wardani, E. (2018). What is the Problem with Nursing Documentation? Perspective of Indonesian Nurses. International Journal of Africa Nursing Sciences, 9(December 2017), 111–114.

Kang, M. J., Rossetti, S. C., Knaplund, C., Chang, F. Y., Schnock, K. O., Whalen, K., Gesner, E. J., Garcia, J. P., Cato, K. D., & Dykes, P. C. (2021). Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System. Computers, Informatics, Nursing : CIN, 39(12), 845–850.

Padila, P., Lina, L. F., Febriawati, H., Agustina, B., & Yanuarti, R. (2018). Home Visit Berbasis Sistem Informasi Manajemen Telenursing. Jurnal Keperawatan Silampari, 2(1), 217-235.

Primadilla, H. (2022). Pemanfaatan m-Health Berbasis Kebutuhan Sistem Informasi pada Upaya Perkesmas: Kasus TBC. Journal of Telenursing (JOTING), 4(1), 225-236.

Sockolow, P. S., Bowles, K. H., Wojciechowicz, C., & Bass, E. J. (2020). Incorporating Home Healthcare Nurses' Admission Information Needs to Inform Data Standards. Journal of the American Medical Informatics Association : JAMIA, 27(8), 1278–1286.

Suganda, T., & Hariyati, R. T. S. (2020). Perbandingan Kualitas Dokumentasi Keperawatan Berbasis Elektronik dan Berbasis Kertas: Study Literature. Holistik Jurnal Kesehatan, 14(1), 17–28.

Supriyana, D. S., & Prasetyawati, A. E. (2020). Pendekatan Home Care untuk Meningkatkan Dukungan Keluarga dalam Manajemen Tuberkulosis Paru pada Pasien Lanjut Usia : Laporan Kasus. Jurnal Stethoscope, 1(1), 23–31.

Yang, Y., Bass, E. J., Bowles, K. H., & Sockolow, P. S. (2019). Impact of Home Care Admission Nurses' Goals on Electronic Health Record Documentation Strategies at the Point of Care. Computers, Informatics, Nursing : CIN, 37(1), 39–46.
Abstract viewed = 161 times
pdf downloaded = 200 times