Strategi peningkatan mutu dokumentasi Keperawatan di era pandemi Covid-19
DOI:
https://doi.org/10.32584/jkmk.v6i2.1491Keywords:
Peningkatan Mutu, Dokumentasi Keperawatan, Panduan dokumentasiAbstract
Dokumentasi keperawatan merupakan cerminan proses keperawatan yang diberikan kepada pasien, mulai dari pengkajian, penetapan diagnosis, perencanaan asuhan keperawatan, implementasi hingga evaluasi. Studi ini bertujuan meningkatakan mutu pelaksanan pendokumentasian asuhan keperawatan di ruang rawat inap RS X pada masa pandemi Covid-19. Metode yang digunakan ialah pilot study. Pengumpulan data dilakukan melalui wawancara terstruktur, survei, observasi dan studi dokumentasi. Proses diawali dengan pengkajian, analisis masalah, menetapkan prioritas masalah, membuat Plan of Action (POA), Implementasi hingga evaluasi. Implementasi berupa penyusunan panduan dokumentasi asuhan Keperawatan, ceklist supervisi kelengkapan dokumentasi keperawatan, promosi panduan diagnosis Keperawatan berbasis Aplikasi Android, dan formulir rencana Asuhan Keperawatan. Hasil studi menunjukan adanya peningkatan yang signifikan pada pelaksanaan dokumentasi keperawatan yaitu peningkatan 5% pada pengkajian, 6.4% pada diagnosis, 30 % pada perencanaan, 27.5% pada implementasi, 15 % pada evaluasi meskipun adanya penurunan sebesar 2% pada aspek catatan keperawatan. Disimpulkan peningkatan mutu pendokumentasian dapat dipengaruhi dengan adanya panduan pendokumentasian keperawatan serta dukungan peran dan fungsi perawat manajer. Studi ini merekomendasikan untuk mengoptimalkan peran supervisi kepala ruangan, mengadakan pelatihan dokumentasi keperawatan dan pengembangan dokumentasi secara terintegrasi kedalam sistem manajemen informasi.
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