Pengembangan Dokumentasi Asuhan Keperawatan di Ruang Perawatan Anak Rumah Sakit Umum Daerah Langsa

Abstract

Documentation of nursing care is evidence that the legal and ethical responsibility of nurses to clients are met and the client has received the quality of nursing care. The purpose of this study was to develop a format for documentation of nursing care in a Pediatric Unit Langsa Regional General Hospital with an approach Action Research (AR). Data collection took place during April 22 until June 15, 2013, with in-depth interviews (in-depth interview), self-report, observation and FGD. Self-report questionnaires conducted using knowledge of nurses and nurse satisfaction questionnaires on the documentation of nursing care. The data were analyzed qualitatively and quantitatively. Qualitative data were analyzed by content analysis. Quantitative data were analyzed with the Wilcoxon test and T-test. Research with action research approach is implemented through three stages of the cycle, namely planning, action and observation and reflection. Outcome of this research is the documentation format nursing care of children. The process of implementation of this action research study showed some positive effects of increased completeness of filling documentation of nursing care. In addition to the knowledge of nurses about nursing care documentation and satisfaction of nurses to nursing care documentation increased significantly following the implementation of the action research process. Research with action research approach that researchers do this successfully increase traffic nurses documenting nursing care in children. Nurse educators and nurse practitioners are advised to use an action research approach as an effective way to make change.

Dokumentasi asuhan keperawatan adalah bukti bahwa tanggung jawab hukum dan etik perawat terhadap klien sudah dipenuhi dan klien telah menerima asuhan keperawatan yang bermutu. Tujuan penelitian ini adalah untuk mengembangkan format dokumentasi asuhan keperawatan di Ruang Perawatan Anak Rumah Sakit Umum Daerah Langsa dengan menggunakan pendekatan Action Research (AR). Pengumpulan data dilaksanakan pada tanggal 22 April 2013 – 15 Juni 2013 dengan metode wawancara mendalam (in-depth interview), self-report, observasi dan FGD. Self-report dilakukan dengan menggunakan kuesioner pengetahuan perawat dan kuesioner kepuasan perawat tentang dokumentasi asuhan keperawatan. Analisis data dilakukan secara kualitatif dan kuantitatif. Data kualitatif dianalisa secara content analysis. Data kuantitatif dianalisa dengan uji Wilcoxon dan T-test. Penelitian dengan pendekatan action research ini dilaksanakan satu siklus melalui tiga tahapan yaitu planning, action dan observation serta reflection. Outcome penelitian ini adalah format dokumentasi asuhan keperawatan anak. Proses pelaksanaan penelitian action research ini menunjukkan beberapa dampak positif yaitu meningkatnya kelengkapan pengisian dokumentasi asuhan keperawatan. Selain itu pengetahuan perawat tentang dokumentasi asuhan keperawatan serta kepuasan perawat terhadap dokumentasi asuhan keperawatan bertambah secara signifikan setelah pelaksanaan proses action research. Penelitian dengan pendekatan action research yang peneliti lakukan ini berhasil meningkatkan kemampuan perawat dalam mendokumentasikan asuhan keperawatan anak. Perawat pendidik maupun perawat praktisi disarankan menggunakan pendekatan action research sebagai cara yang efektif untuk membuat perubahan.