Hubungan Karakteristik Individu dan Organisasi dengan Kinerja Perawat dalam Pendokumentasian Asuhan Keperawatan di Rumah Sakit Tingkat II Putri Hijau Kesdam I Bukit Barisan Medan

Abstract

Documenting nursing care in a medical record file has an important function and role in the continuity of nursing care implementation for the patients and is also beneficial as legal evidence. The performance of the nurses working for Putri Hijau Level II Hospital Kesdam I Bukit Barisan Medan in documenting nursing care in medical record found was that 75% assessment, 65% action plan, 65% records of activities, and 75% of the procedures of filling in the nurses’ resume were not complete. The purpose of this explanatory study conducted from March to June 2012 was to analyze the relationship between individual characteristics and organization with the performance of the nurses in documenting nursing care at Putri Hijau Level II Hospital Kesdam I Bukit Barisan Medan. The population of this study was all of the 169 nurses working for this hospital and 156 of them were selected to be the samples for this study. The data for this study were obtained through observation and questionnaire-based interviews. The data obtained were analyzed through multiple logistic regression tests at α = 0.05. The result of this study showed that statistically individual characteristics and organization had a significant relationship with the performance of the nurses in documenting nursing care. The variable of knowledge had a bigger influence on the performance of the nurses. The management of Hospital is suggested: to improve the knowledge and experience of the nurses through periodical trainings and to give the nurses the chance to attend seminars on nursing care documentation, to increase the socialization on the importance of completely filling out the medical record and the periodical and continuous benefit of medical record, to socialize the work design to all of the nurses working at this hospital that the nurses correctly understand the design applied and can make it guidance in implementing the activities of nursing care documentation, and to complete work facilities such as the provision of the forms for nursing care medical record and the stationery for nursing care documentation.

Pendokumentasian asuhan keperawatan pada rekam medis mempunyai fungsi dan peranan yang penting dalam kesinambungan pelaksanaan asuhan keperawatan pasien serta bermanfaat menjadi bukti hukum. Kinerja perawat di Rumah Sakit Tingkat II Putri Hijau Kesdam I/Bukit Barisan Medan dalam pendokumentasian asuhan keperawatan pada rekam medis ditemukan 75% pengkajian, 65% rencana kegiatan, 65% catatan kegiatan, dan 75% resume keperawatan pengisiannya kurang lengkap. Penelitian ini bertujuan untuk menganalisis hubungan karakteristik individu dan organisasi dengan kinerja perawat dalam pendokumentasian asuhan keperawatan di Rumah Sakit Tingkat II Putri Hijau Kesdam I Bukit Barisan Medan. Jenis penelitian survei explanatory. Penelitian ini dilaksanakan bulan Maret sampai dengan Juni 2012. Populasi adalah seluruh perawat pelaksana sebanyak 169 orang dan sampel sebanyak 156 orang. Data diperoleh dengan wawancara dan observasi menggunakan kuesioner, dianalisis dengan regresi logistik berganda pada pengujian α=0.05. Hasil penelitian menunjukkan karakteristik individu dan karakteristik organisasi berhubungan signifikan dengan kinerja perawat dalam pendokumentasian asuhan keperawatan. Variabel pengetahuan berpengaruh lebih besar terhadap kinerja perawat. Disarankan kepada manajemen Rumah Sakit untuk: mengupayakan peningkatan pengetahuan dan pengalaman perawat melalui pelatihan secara berkala dan memberikan kesempatan untuk mengikuti seminar tentang pendokumentasian asuhan keperawatan, meningkatkan sosialisasi tentang pentingnya kelengkapan pengisian rekam medis dan manfaat rekam medis secara berkala dan berkesinambungan, mensosialisasikan desain kerja pada seluruh perawat di lingkungan rumah sakit, sehingga para perawat memahami secara benar mengenai desain yang diterapkan serta dapat dipedomani dalam menjalankan kegiatan pendokumentasian asuhan keperawatan, dan mengupayakan kelengkapan fasilitas kerja seperti penyediaan form rekam medis dan alat tulis untuk keperluan pendokumentasian asuhan keperawatan.