Optimalisasi Penegakan Diagnosis Keperawatan Sesuai Standar Asuhan Keperawatan di Rumah Sakit X
Abstract
This study aims to analyze the enforcement of nursing diagnoses according to the Nursing Care Standards of X Hospital Jakarta. The research method uses a case study approach with interviews, document review and observation, and performs problem analysis using fishbone analysis. The results showed that the enforcement of nursing diagnoses in accordance with the Standards of Nursing Care was not optimal, so that it had an impact on the quality of care and its documentation. Nursing diagnoses that are in accordance with Nursing Care Standards are 48.6%. Lack of supervision from managers, assessments using personal assumptions and the standard of writing diagnoses in the local Hospital Information System (SIRS) has not been facilitated. Through strengthening the directing function with SAK media innovation, there was an increase in writing nursing diagnoses according to SAK to 62.3%. In conclusion, optimizing the enforcement of nursing diagnoses in accordance with Nursing Care Standards can be implemented with SAK media innovations (Softfiles on the Google Form Platform and flipcharts) which are given to implementing nurses at X Hospital.
Keywords: Diagnosis, Nursing Documentation, Quality, Nursing Care Standards
References
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Atmanto, A. P., Aggorowati, A., & Rofii, M. (2020). Efektifitas Pedoman Pendokumentasian Diagnosa dan Intervensi Keperawatan Berbasis Android tgerhadap Peningkatan Mutu Dokumentasi Keperawatan di Ruang Rawat Inap. Jurnal Keperawatan dan Kesehatan Masyarakat Cendekia Utama, 9(1), 83. https://doi.org/10.31596/Jcu.V9i1.517
Banunaek, C. D., Dewi, Y. E. P., & Andadari, R. K. (2021). Dilema Etik pada Profesionalisme Perawat terhadap Kualitas Pelayanan Keperawatan. Jurnal Kepemimpinan dan Manajemen Keperawatan, 4(2), 110–120. Https://doi.org/10.32584/Jkmk.V4i2.1143
De Groot, K., De Veer, A. J. E., Munster, A. M., Francke, A. L., & Paans, W. (2022). Nursing Documentation and its Relationship with Perceived Nursing Workload: A Mixed-Methods Study Among Community Nurses. BMC Nursing, 21(1), 34. https://doi.org/10.1186/S12912-022-00811-7
Häyrinen, K., Lammintakanen, J., & Saranto, K. (2010). Evaluation of Electronic Nursing Documentation—Nursing Process Model and Standardized Terminologies as Keys to Visible and Transparent Nursing. International Journal Of Medical Informatics, 79(8), 554–564. https://doi.org/10.1016/J.Ijmedinf.2010.05.002
Meidianta, A. C., & Milkhatun, M. (2020). Hubungan Antara Pelatihan Proses Keperawatan dengan Pengetahuan Perawat gtentang Penerapan Standar Diagnosis Keperawatan Indonesia di RSUD Samarinda. Borneo Studies and Research, 1(2), 647-651. https://journals.umkt.ac.id/index.php/bsr/article/view/1020/377
Moldskred, P. S., Snibsøer, A. K., & Espehaug, B. (2021). Improving the Quality of Nursing Documentation at A Residential Care Home: A Clinical Audit. BMC Nursing, 20(1), 103. https://doi.org/10.1186/S12912-021-00629-9
Mongi, T. O. (2021). Hubungan Fungsi Pengarahan Kepala Ruangan dengan Pelaksanaan Dokumentasi Asuahan Keperawatan. Jurnal Ilmiah Kesehatan Diagnosis, 16(4), 173-179. https://jurnal.stikesnh.ac.id/index.php/jikd/article/view/834
N Widodo, W., Wungow, H., & Hamel, S. R. (2016). Hubungan Peran Ketua Tim dengan Kinerja Perawat Pelaksana dalam Pendokumentasian Asuhan Keperawatan di Irina F RSUP Prof Dr. R. D. Kandou Manado. E-Journal Keperawatan, 4(2). https:/?doi.org/Https://Doi.Org/10.35790/Jkp.V4i2.12871
Panjaitan, Y., Rahman, L., Hariyati, R., & Nur, Y. (2022). Optimalisasi Supervisi Kepala Ruangan terhadap Peningkatan Pelayanan Bermutu di Rumah Sakit. Journal Of Telenursing (JOTING), 4(1), 197-204. https://doi.org/10.31539/joting.v4i1.3214
Pranatha, A., & Nugraha, Moch. D. (2023). Pengaruh Penerapan Standar Nursing Language Berbasis SDKI, SLKI, SIKI terhadap Kualitas Pengisian Dokumentasi Keperawatan di Rumah Sakit Juanda Kuningan. Jurnal Ilmu Kesehatan Bhakti Husada: Health Sciences Journal, 14(01), 59–67. https://doi.org/10.34305/Jikbh.V14i01.711
Qin, Y., Zhou, R., Wu, Q., Huang, X., Chen, X., Wang, W., Wang, X., Xu, H., Zheng, J., Qian, S., Bai, C., & Yu, P. (2017). The Effect of Nursing Participation In The Design of A Critical Care Information System: A Case Study In A Chinese Hospital. BMC Medical Informatics And Decision Making, 17(1), 165. https://doi.org/10.1186/S12911-017-0569-3
Robbins, S. P., & Judge, T. A. (2019). Organizational Behavior (18th Ed.). Pearson Education.
Slyngstad, L., & Helgheim, B. I. (2022). How Do Different Health Record Systems Affect Home Health Care? A Cross-Sectional Study Of Electronic- Versus Manual Documentation System. International Journal Of General Medicine, 15, 1945–1956. https://doi.org/10.2147/IJGM.S346366
Sudaryati, S., Afriani, T., Hariyati, Rr. T., Herawati, R., & Yunita, Y. (2022). Diskusi Refleksi Kasus (DRK) Efektif Meningkatkan Kemampuan Perawat Dalam Melakukan Dokumentasi Keperawatan Sesuai Standar 3s (SDKI, SLKI, SIKI). Jurnal Keperawatan Silampari, 5(2), 823–830. https://doi.org/10.31539/Jks.V5i2.3461
Suryono, S., & Nugroho, C. (2020). Kompetensi Perawat Mendokumentasikan Diagnosis Keperawatan Berdasarkan Standar Diagnosis Keperawatan Indonesia (SDKI). Jurnal ILKES(Jurnal Ilmu Kesehatan), 11(1), 233-238. https://doi.org/10.35966/ilkes.v11i1.168
Undang-Undang Nomor 38 Tentang Keperawatan. (2014).
Wang, N., Hailey, D., & Yu, P. (2011). Quality of Nursing Documentation and Approaches to Its Evaluation: A Mixed-Method Systematic Review. Journal Of Advanced Nursing, 67(9), 1858–1875. https://doi.org/10.1111/J.1365-2648.2011.05634.X
Washilah, W., Suhartini, T., Hadi, W. N., Hafshawaty, S., Zainul, P., Probolinggo, H., Stikes, W. W., Pesantren, H., Hasan, Z., & Email, P. (2023). Analisis Faktor yang Mempengaruhi Kualitas Dokumentasi Keperawatan. In Media Husada Journal Of Nursing Science, 4(1). https://mhjns.widyagamahusada.ac.id
Zulkarnain, Z. (2019). Analisis Pelaksanaan Fungsi Manajemen Pengarahan Kepala Ruangan Dengan Kinerja Perawat Dalam Menerapakan Asuhan Keperawatan Di Ruang Rawat Inap RSUD Bima. JISIP (Jurnal Ilmu Sosial dan Pendidikan), 1(2). http://dx.doi.org/10.58258/jisip.v1i2.356
