The Influence of Nursing Care Documenting Behavior to the Completeness of Nursing Care Documentation at Hospital X

Abstract

Nursing care documentation is a written evidence of nursing process given to the patient. It is very important to both the health care team, the patient and the hospital. The completeness of nursing care documentation at hospital X in February 2017 are 76.3% in assessment, 86.4% in diagnosis, 93.3% in planning, 96% in implementation and 92.2% in an evaluation. The purpose of this research is to discover the factors that influence the completeness of nursing care documentation at hospital X. This research is an analytical survey using cross-sectional study with 89 nurses as its samples. The data are analyzed using chi-square and multiple linear regression. The completeness of nursing care documentation is affected by knowledge (χ2 12.776), attitude (17.692) and supervision (14.417). The availability of nursing facilities has no influence on the completeness of nursing care documentation (3.384). Knowledge, attitude, availability of facilities and supervision has an influence on the completeness of nursing care documentation at 34.1%. The variable with the highest influence on the completeness of nursing care documentation is supervision (B 0.180). Knowledge, attitude, and supervision have an influence on the completeness of nursing care documentation. The availability of facilities has no influence on it and the one with the highest influence is supervision. Dokumentasi asuhan keperawatan merupakan bukti tertulis dari proses keperawatan yang diberikan perawat kepada pasien, berguna bagi pasien, tim kesehatan lain dan rumah sakit. Data kelengkapan dokumentasi asuhan keperawatan di RS X bulan Februari 2017 adalah pengkajian 76,3%, diagnosa 86,14%, perencanaan 93,3%, tindakan 96% dan evaluasi 92,2%. Tujuan penelitian untuk mengetahui faktor yang berpengaruh terhadap kelengkapan dokumentasi asuhan keperawatan di RS. Jenis penelitian ini survey analatik pendekatan crosss-sectional dengan sampel sebanyak 89 perawat. Analisis data menggunakan chi-square dan regresi linear berganda. Kelengkapan dokumentasi asuhan keperawatan dipengaruhi oleh pengetahuan (χ² 12,776), sikap (17,692), dan supervisi (14,417). Ketersediaan fasilitas tidak berpengaruh terhadap kelengkapan dokumentasi keperawatan (3.3841). Pengetahuan, sikap, ketersediaan fasilitas dan supervisi secara bersama-sama berpengaruh terhadap kelengkapan dokumentasi asuhan keperawatan sebesar 34.1%. Variabel yang paling berpengaruh terhadap kelengkapan dokumentasi asuhan keperawatan adalah supervisi (B 0.180). Pengetahuan, sikap dan supervisi berpengaruh terhadap kelengkapan dokumentasi asuhan keperawatan. Ketersediaan fasilitas tidak berpengaruh terhadap kelengkapan dokumentasi asuhan keperawatan. Supervisi paling berpengaruh terhadap kelengkapan dokumentasi asuhan keperawatan.