Efektivitas Pelatihan dan Supervisi terhadap Peningkatan Kualitas Pendokumentasian Asuhan Keperawatan : Literature Review
The Effectiviness of Training and Supervision on Improving the Quality of Nursing Care Documentation : Literatur Review
Abstract
Latar Belakang: Pelayanan asuhan keperawatan yang berkualitas dapat diwujudkan melalui kelengkapan dokumentasi. Pada kenyataannya masih ditemukan dokumentasi asuhan keperawatan yang tidak lengkap masih menjadi permasalahan di rumah sakit. Salah satu faktor yang mempengaruhi praktik dokumentasi keperawatan adalah supervisi, sikap perawat, pelatihan, perbandingan perawat-pasien, motivasi dan pengetahuan perawat.
Tujuan: Penelitian ini dilakukan untuk melihat hubungan Efektivitas Pelatihan Dan Supervisi Terhadap Peningkatan Kualitas Pendokumentasian Asuhan Keperawatan.
Metode: Jurnal yang digunakan dalam literature review berjumlah 10 jurnal. Penulusuran jurnal dilakukan melalui tiga database yaitu EBSCO, ProQuest, dan Google Scholar.
Hasil: Hasil yang didapatkan yaitu adanya pengaruh antara supervisi dan pengetahuan terhadap pendokumentasian asuhan keperawatan, supervisor dalam hal ini kepala ruangan berperan dalam mengarahkan perawat terutama dalam pendokumentasian asuhan keperawatan. Peran dari pengetahun perawat itu sendiri perlu ditingkatkan agar dokumentasi asuhan keperawatan dapat dilakukan dengan optimal. Pentingnya peran manajerial untuk melakukan pelatihan pendokumentasian asuhan keperawatan pada perawat pelaksana.
Kesimpulan: Implentasi pendokumentasian dengan supervise baik menggunakan elektronik atau paper based yang berformat dapat meningkatkan kualitas pendokumentasian asuhan keperawatan. Hal ini akan berdampak positif terhadap kepercayaan diri dan motivasi perawat dalam pendokumentasian.
References
Peraturan Menteri Kesehatan Republik Indonesia No 26 Tahun 2019
Peraturan Menteri Kesehatan Republik Indonesia No 56 Tahun 2014
A, A., T, A., M, S., T, L., A, E., B, B., & M, G. (2019). Knowledge, attitude, practice and associated factors towards nursing care documentation among nurses in West Gojjam Zone public hospitals, Amhara Ethiopia, 2018. Clinical Journal of Nursing Care and Practice, 3(1), 001–013. https://doi.org/10.29328/journal.cjncp.1001010
Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing care activities based on documentation. BMC Nursing, 18(Suppl 1), 1–5. https://doi.org/10.1186/s12912-019-0352-0
Asamani, J. A., Amenorpe, F. D., Babanawo, F., & Ofei, A. M. A. (2014). Nursing documentation of inpatient care in eastern Ghana. British Journal of Nursing, 23(1), 48-54.
Dr.dr.Sutoto, M.Kes, Fisq. (2022). Instrumen Survei Akreditasi KARS sesuai Standar Akreditasi RS Kemenkes R.I.2022 (Mei 2022, Vol. 1).
Hariyati, R. T. S., & Ungsianik, T. (2018). Improving the interpersonal competences of head nurses through Peplau's theoretical active learning approach. Enfermeria clinica, 28, 149-153.
Kamil, H., Rachmah, R., & Wardani, E. (2018). What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences, 9(December 2017), 111–114. https://doi.org/10.1016/j.ijans.2018.09.002
Kartini, M., & Ratnawati, E. (2022). The Effectiveness of Nursing Documentation Training on Nurse's Knowledge about SDKI, SLKI, and SIKI. Jurnal Kesehatan, 11(1), 47-51
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
Manuhutu, F., Novita, R. V. T., Supardi, S., Litbangkes, B., & Ri, K. (n.d.). Setelah Dilakukan Pelatihan Supervisi Kepala Ruang Di Rumah Sakit X , Kota Ambon [ Documentation of Nursing Care By Nurses After Supervision Training for Head Nurses Et X Hospital Ambon City ]. 171–191.
Moen, H., Hakala, K., Peltonen, L. M., Matinolli, H. M., Suhonen, H., Terho, K., Danielsson-Ojala, R., Valta, M., Ginter, F., Salakoski, T., & Salanterä, S. (2020). Assisting nurses in care documentation: From automated sentence classification to coherent document structures with subject headings. Journal of Biomedical Semantics, 11(1), 1–13. https://doi.org/10.1186/s13326-020-00229-7
Peraturan Menteri Kesehatan Republik Indonesia No 26 Tahun 2019
Peraturan Menteri Kesehatan Republik Indonesia No 56 Tahun 2014
A, A., T, A., M, S., T, L., A, E., B, B., & M, G. (2019). Knowledge, attitude, practice and associated factors towards nursing care documentation among nurses in West Gojjam Zone public hospitals, Amhara Ethiopia, 2018. Clinical Journal of Nursing Care and Practice, 3(1), 001–013. https://doi.org/10.29328/journal.cjncp.1001010
Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing care activities based on documentation. BMC Nursing, 18(Suppl 1), 1–5. https://doi.org/10.1186/s12912-019-0352-0
Dr.dr.Sutoto, M.Kes, Fisq. (2022). Instrumen Survei Akreditasi KARS sesuai Standar Akreditasi RS Kemenkes R.I.2022 (Mei 2022, Vol. 1).
Hariyati, R. T. S., & Ungsianik, T. (2018). Improving the interpersonal competences of head nurses through Peplau's theoretical active learning approach. Enfermeria clinica, 28, 149-153.
Kamil, H., Rachmah, R., & Wardani, E. (2018). What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences, 9(December 2017), 111–114. https://doi.org/10.1016/j.ijans.2018.09.002
Kartini, M., & Ratnawati, E. (2022). The Effectiveness of Nursing Documentation Training on Nurse's Knowledge about SDKI, SLKI, and SIKI. Jurnal Kesehatan, 11(1), 47-51
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
Manuhutu, F., Novita, R. V. T., Supardi, S., Litbangkes, B., & Ri, K. (n.d.). Setelah Dilakukan Pelatihan Supervisi Kepala Ruang Di Rumah Sakit X , Kota Ambon [ Documentation of Nursing Care By Nurses After Supervision Training for Head Nurses Et X Hospital Ambon City ]. 171–191.
Moen, H., Hakala, K., Peltonen, L. M., Matinolli, H. M., Suhonen, H., Terho, K., Danielsson-Ojala, R., Valta, M., Ginter, F., Salakoski, T., & Salanterä, S. (2020). Assisting nurses in care documentation: From automated sentence classification to coherent document structures with subject headings. Journal of Biomedical Semantics, 11(1), 1–13. https://doi.org/10.1186/s13326-020-00229-7
Nopriyanto, D., Hariyati, R. T. S., & Ungsianik, T. (2019). Improving documentation of patient progress note through role empowerment of head nurse by Orlando theory approach. EnfermerÃa ClÃnica, 29, 182-188.
Oktaviani, M. H., Hartiti, T., & Hasib, M. (2019). Supervisi Untuk Meningkatkan Kemampuan Perawat dalam Timbang Terima: Literature Review. Jurnal Kesehatan Masyarakat, 12.
Oliveira, N. B. De. (2021). Quality of the documentation of the Nursing process in clinical decision support systems *. https://doi.org/10.1590/1518-8345.4510.3426
Pengabdian Masyarakat, J., Sumarni, T., Sekar Siwi, A., Nur, A. R., Suhendro, A., Harapan Bangsa, U., Raden Patah No, J., Kembaran Banyumas, L., & Tengah, J. (2022). PIMAS Penerapan Dokumentasi Keperawatan Menggunakan 3S (SDKI, SLKI, SIKI) di RSI Banjarnegara. Jurnal Pengabdian Masyarakat (PIMAS), 1(4). https://doi.org/10.35960/pimas.v1i4.891
Puspitasari, N. W., Nurkholis, N., Atmanto, A. P., Zuhri, M., Sulistiyaningsih, S., Diel, M. M., ... & Dwidiyanti, M. (2018). Supervisi Klinik Dalam Pelayanan Keperawatan Sebagai Upaya Peningkatan Kompetensi Perawat Di Rumah Sakit. Jurnal Perawat Indonesia, 2(2), 51-61
Saraswasta, I. W. G., Tutik, R., Hariyati, S., & Fatmawati, U. (2020). Pelaksanaan Dokumentasi Asuhan Keperawatan Di Ruang Rawat Inap Rumah Sakit X Jakarta : Pilot Study. February, 199–207. https://doi.org/10.20527/dk.v8i1.8024
Semachew, A. (2018). Implementation of nursing process in clinical settings: The case of three governmental hospitals in Ethiopia, 2017. BMC Research Notes, 11(1), 4–8. https://doi.org/10.1186/s13104-018-3275-z
Sobari, A., Nyorong, M., & Nuraini, N. (2022). Faktor yang berhubungan dengan Catatan Keperawatan Dokumen Rekam Medis Rawat Inap di Rumah Sakit H. Adam Malik Medan. JUMANTIK (Jurnal Ilmiah Penelitian Kesehatan), 7(4), 395-405
Tamir, T., Geda, B., & Mengistie, B. (2021). Documentation practice and associated factors among nurses in harari regional state and dire dawa administration governmental hospitals, eastern ethiopia. Advances in Medical Education and Practice, 12, 453–462. https://doi.org/10.2147/AMEP.S298675
Vafaei, S. M., Manzari, Z. S., Heydari, A., Froutan, R., & Farahani, L. A. (2018). Nurses’ perception of nursing services documentation barriers: A qualitative approach. Electronic Journal of General Medicine, 15(3)
Wanti, V., Arif, Y., & Murni, D. (2022). Relationship Analysis of Supervision Implementation of CPPT In General Hospital University Riau. Journal Research of Social, Science, Economics, and Management, 2(03), 291-300.
Yulianita, H., Tutik, R., Hariyati, S., Pujasari, H., Komariah, M., & Fitria, N. (2020). Improving the quality of nursing documentation using supervision of the head of room. EurAsian Journal of BioSciences Eurasia J Biosci, 14(January 2021), 7579–7584.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution-Non Commercial License that allows others to share the work with an acknowledgment of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
The content of this website is licensed under a Creative Commons Attribution-ShareAlike 4.0 International (CC BY-SA 4.0) license. 
