PENGARUH PELATIHAN SISTEM PENDOKUMENTASIAN NANDA-I NIC NOC (NNN) TERHADAP KUALITAS DOKUMENTASI ASUHAN KEPERAWATAN DI RUANG PERINATAL RSUD KOTA YOGYAKARTA

ENNY EKO S, Intansari Nurjannah, S,Kp.,M.N.Sc.,Ph.D.; Anik Rustiyaningsih, S.Kep.,Ns.,M.Kep.,Ns.Sp.Kep.An

2019 | Tesis | MAGISTER KEPERAWATAN

Background: Standar bahasa keperawatan yang ada antara lain adalah NNN. Itu terdiri dari NANDA-I untuk standar bahasa diagnosis, Nursing Intervention Classification (NIC) untuk intervensi keperawatan, dan Nursing Outcome Classification (NOC) untuk luaran keperawatan. Salah satu cara untuk meningkatkan kualitas dari dokumentasi asuhan keperawatan adalah dengan diberikan pelatihan mengenai system dokumentasi. Objectives: Mengetahui pengaruh pemberian pelatihan sistem pendokumentasian asuhan keperawatan NANDA-I, NIC dan NOC (NNN) terhadap kualitas dokumentasi keperawatan. Methods: Jenis penelitian menggunakan quasi experimental dengan rancangan pre-post tanpa grup kontrol. Penelitian dilakukan dengan melakukan pelatihan pada perawat (n=21) yang berada di ruang perinatal observasi pada rekam medis (n=86) dilakukan sebelum pelatihan dan 14 hari setelah pelatihan (n=86). Intervensi yang diberikan adalah pelatihan yang terdiri dari tiga tahap yaitu, seminar/ceramah, mentoring, dan evaluasi. Media yang digunakan untuk pelatihan adalah powerpoint, modul dan buku saku. Lembar observasi kualitas dokumentasi keperawatan menggunakan Q-DIO yang telah dimodifikasi. Uji statistik yang digunakan adalah independent samples t-test dengan tingkat kepercayaan 95%. Results: Terjadi peningkatan rerata 0,86 dengan rata-rata sebelum pelatihan 1,91 dan sesudah pelatihan 2,78. Terdapat perbedaan yang signifikan sebelum dan sesudah pelatihan dengan nilai p<0,001. Conclusion: Pelatihan sistem dokumentasi keperawatan NNN dengan metode ceramah, mentoring dan evaluasi dengan menggunakan powerpoint, modul dan buku saku dapat meningkatkan kualitas dokumentasi keperawatan di Ruang Perinatal RSUD Kota Yogyakarta.

Background: The existing standard of nursing language includes using NNN, which consists of NANDA-I for diagnostic language standard, Nursing Intervention Classification (NIC) for nursing intervention, and Nursing Outcome Classification (NOC) for nursing outcomes. One way to improve the quality of nursing care documentation is to be given documentation systemprovide training in documentation system. Objectives: Determine the effect of providing NANDA-I, NIC and NOC (NNN) nursing care documentation systems training on the quality of nursing documentation. Methods: This type of research uses quasi experimental with a pre-post design without a control group. As many as The study was conducted by 21 training nurses (n = 21) nurses who wereworks in the perinatal ward involved in this study. Those nurses were trained for nursing care documentation system. The quality of nursing care documentation Observation sheet for nursing quality documentationwas measured using modified Q-DIO. The nursing documentation was collected by collecting mMedical record observed (n = 86). Those medical record were measured 7 before training and 14 days after training. (n = 86). The intervention provided is training which consists of three stages: seminar / lecture, mentoring, and evaluation. The media used for training are powerpoints, modules and pocket books. Observation sheet for nursing quality documentation using modified Q-DIO. Data analysis used The statistical test used independent samples t-test with a confidence level of 95%. Results: The mean score of the quality of nursing documentation before training was 1,91 (less good) and the mean score of the quality of nursing documentation after training was 2, 78 (good). There was an average increase of 0.86 with an average before training 1.91 and after training 2.78. There were significant differences before and after training with a value of p <0.001. Conclusion: Training of NNN nursing documentation system with lecture, mentoring and evaluation methods using modules, pocket books and power-point can improve the quality of nursing documentation in the perinatal ward of Yogyakarta Regional Public Hospital in Yogyakarta Indonesia.

Kata Kunci : pelatihan, kualtas dokumentasi asuhan keperawatan, NANDA-I