Optimalisasi Kualitas Dokumentasi Asuhan Keperawatan dengan Pendekatan SOAP di Rawat Jalan Anak: Pilot Study
Abstract
This study aims to find the root of the problem to streamline documentation in outpatient care. The method in this research is a case study using a particular pilot study approach for nurses in outpatient rooms for children through Kurt Lewin's theory of change. Problem analysis was performed using a fishbone. The implementation is carried out as a solution to the problems that occur in drafting a Standard Operating Procedure and a monitoring format for monitoring the evaluation of nursing care documentation using the SOAP approach and socializing innovation products. The research results with fishbone analysis showed that the quality of nursing care documentation using the SOAP approach in outpatient rooms for children was not up to standard. In conclusion, the root of the problem is identified. The implementation of a pilot study related to the optimization of the quality of nursing care documentation. Hospital X is at the stage of moving/movement change. Innovative products are socialized and accepted for further instrument testing.
Keywords: Evaluation, Documentation Quality, Documentation Optimization
References
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Warashati, D., Novieastari, E., & Afriani, T. (2020). Optimalisasi Peran dan Fungsi Kepala Ruangan dalam Pelaksanaan Sosialisasi Regulasi dan Standar Prosedur Operasional Keselamatan Pasien. Jurnal Keperawatan Komprehensif (Comprehensive Nursing Journal), 6(2), 85-94. https://doi.org/10.33755/jkk.v6i2.165
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Akhu-Zaheya, L., Al-Maaitah, R., & Bany Hani, S. (2018). Quality of Nursing Documentation: Paper-Based Health Records Versus Electronic-Based Health Records. Journal of Clinical Nursing, 27(3-4), 578-589. https://doi.org/10.1111/jocn.14097
Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing Care Activities Based on Documentation. BMC Nursing, 18(32), 1-5. https://doi.org/10.1186/s12912-019-0352-0
Baraki, Z., Girmay, F., Kidanu, K., Gerensea, H., Gezehgne, D., & Teklay, H. (2017). A Cross Sectional Study on Nursing Process Implementation and Associated Factors among Nurses Working in Selected Hospitals of Central and Northwest Zones, Tigray Region, Ethiopia. BMC Nursing, 16(1), 54. https://doi.org/10.1186/s12912-017-0248-9
Cho, S.-H., Lee, J.-Y., Hong, K. J., Yoon, H.-J., Sim, W.-H., Kim, M.-S., & Huh, I. (2020). Determining Nurse Staffing by Classifying Patients Based on Their Nursing Care Needs. J Korean Acad Nurs Adm, 26(1), 42-54. https://doi.org/10.11111/jkana.2020.26.1.42
Dahlia, A. I., Novieastari, E., & Afriani, T. (2020). Supervisi Klinis Berjenjang sebagai Upaya Pemberian Asuhan Keperawatan yang Aman Terhadap Pasien. Dunia Keperawatan: Jurnal Keperawatan dan Kesehatan, 8(2), 304-312. https://doi.org/10.20527/dk.v8i2.7757
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. https://doi.org/10.1111/jan.13919
Dwisatyadini, M., Hariyati, R. T. S., & Afifah, E. (2018). The Effects of the Application of SIMPRO on the Completeness and Time Efficiency of Nursing Documentation in the Outpatient Installation at Dompet Dhuafa Hospital Parung. IOP Conference Series: Materials Science and Engineering, 332, 1-8. https://doi.org/10.1088/1757-899x/332/1/012034
Hariyati, R. T. S., Hamid, A. Y., Eryando, T., & Hasibuan, Z. A. (2020). Usability and Satisfaction of Using Electronic Nursing Documentation, Lesson-Learned from New System Implementation at a Hospital in Indonesia. International Journal of Healthcare Management, 13(1), 45-52. https://doi.org/10.1080/20479700.2018.1504387
Hariyati, R. T. S., Malawat, K. Y., Purwandari, R., & Afifah, E. (2018). Improvement Legal Aspects and Completeness of Documentation Using Record: A Report of Study. International Journal of Nursing and Health Services (IJNHS), 1(2), 32-39. https://doi.org/10.35654/ijnhs.v1i2.46
Iula, A., Ialungo, C., de Waure, C., Raponi, M., Burgazzoli, M., Zega, M., & Damiani, G. (2020). Quality of Care: Ecological Study for the Evaluation of Completeness and Accuracy in Nursing Assessment. International Journal of Environmental Research and Public Health, 17(9), 3259. https://doi.org/10.3390/ijerph17093259
Kebede, M., Endris, Y., & Zegeye, D. T. (2017). Nursing Care Documentation Practice: The Unfinished Task of Nursing Care in the University of Gondar Hospital. Informatics for Health and Social Care, 42(3), 290-302. https://doi.org/10.1080/17538157.2016.1252766
Komisi Akreditasi Rumah Sakit. (2018). Standar Akreditasi Rumah Sakit Edisi 1. http://web90.opencloud.dssdi.ugm.ac.id/wp-content/uploads/sites/644/2018/05/SNARS-Edisi-1.pdf
Nilasari, P., Hariyati, R. T. S., & Anisah, S. (2020). Analisis SWOT Asuhan Keperawatan yang Terlewatkan. Jurnal Keperawatan, 12(1), 125-134. https://doi.org/10.32583/keperawatan.v12i1.709
Ogbolu, Y., Scrandis, D. A., & Fitzpatrick, G. (2018). Barriers and Facilitators of Care for Diverse Patients: Nurse Leader Perspectives and Nurse Manager Implications. Journal of Nursing Management, 26(1), 3-10. https://doi.org/10.1111/jonm.12498
Rafferty, A. M. (2018). Nurses as Change Agents for a Better Future in Health Care: The Politics of Drift and Dilution. Health Economics, Policy and Law, 13(3-4), 475-491. https://doi.org/10.1017/S1744133117000482
Saraswasta, I. W. G., Hariyati, R. T. S., & Fatmawati, U. (2020). Pelaksanaan Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap Rumah Sakit X Jakarta: Pilot Study. Dunia Keperawatan: Jurnal Keperawatan dan Kesehatan, 8(2), 199-207. https://doi.org/10.20527/dk.v8i1.8024
Smith, J. G. (2020). Missed Nursing Care is an Urgent Practice Problem. International Journal of Nursing Practice, 26(1), 12815. https://doi.org/10.1111/ijn.12815
Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2019). Unsafe Nursing Documentation: A Qualitative Content Analysis. Nursing Ethics, 27(5), 1213-1224. https://doi.org/10.1177/0969733019871682
Tasew, H., Mariye, T., & Teklay, G. (2019). Nursing Documentation Practice and Associated Factors among Nurses in Public Hospitals, Tigray, Ethiopia. BMC Research Notes, 12(1), 612-617. https://doi.org/10.1186/s13104-019-4661-x
Tuinman, A., de Greef, M. H. G., Krijnen, W. P., Paans, W., & Roodbol, P. F. (2017). Accuracy of Documentation in the Nursing Care Plan in Long-Term Institutional Care. Geriatric Nursing, 38(6), 578-583. https://doi.org/10.1016/j.gerinurse.2017.04.007
Warashati, D., Novieastari, E., & Afriani, T. (2020). Optimalisasi Peran dan Fungsi Kepala Ruangan dalam Pelaksanaan Sosialisasi Regulasi dan Standar Prosedur Operasional Keselamatan Pasien. Jurnal Keperawatan Komprehensif (Comprehensive Nursing Journal), 6(2), 85-94. https://doi.org/10.33755/jkk.v6i2.165
Wigatama, A. S., Munawaroh, S., & Dwirahayu, Y. (2020). Literature Review: Hubungan Motivasi Kerja Perawat dengan Kinerja Perawat dalam Pengisian Dokumentasi Asuhan Keperawatan. Health Sciences Journal, 4(2), 47-56. http://dx.doi.org/10.24269/hsj.v4i2.513
Yani, F., Wahyuni, F. S., & Priscilla, V. (2019). Analisis Hubungan Manajerial Kepala Ruangan dan Faktor-Faktor yang Mempengaruhi Kinerja Perawat dengan Kualitas Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap RSUD Pariaman. Jurnal Ilmiah Universitas Batanghari Jambi, 19(3), 490-496. http://dx.doi.org/10.33087/jiubj.v19i3.662
Zendrato, M. V., & Hariyati, R. T. S. (2018). Optimalisasi Pengelolaan Asuhan Keperawatan di Instalasi Rawat Jalan Rumah Sakit X. Jurnal Persatuan Perawat Nasional Indonesia (JPPNI), 2(2), 85-99. http://dx.doi.org/10.32419/jppni.v2i2.86
Zendrato, M. V., Hariyati, R. T. S., & Afifah, E. (2019). Outpatient Nursing Care Implementations in Indonesian Regional Public Hospitals. EnfermerÃa ClÃnica, 29, 449-454. https://doi.org/10.1016/j.enfcli.2019.04.066
