ANALISIS KEBUTUHAN RENCANA PENGEMBANGAN DOKUMENTASI ASUHAN KEPERAWATAN ELEKTRONIK DI RUMAH SAKIT UMUM Dr. KANUJOSO DJATIWIBOWO BALIKPAPAN

Syamsul Hadi, dr. Lutfan Lazuardi, M.Kes., Ph.D.

2011 | Tesis | S2 Ilmu Kesehatan Masyarakat

Latar Belakang: Dokumentasi asuhan keperawatan adalah rangkaian kegiatan yang dilakukan oleh perawat dimulai dari proses pengkajian, diagnosa, rencana tindakan, tindakan keperawatan dan evaluasi yang dicatat baik berupa elektronik maupun manual serta dapat dipertanggungjawabkan. Dibandingkan dengan paper based, dokumentasi elektronik lebih cepat, tepat waktu, serta lebih jelas dalam memberikan informasi tentang tindakan yang telah diberikan. Keuntungan dari penggunaan komputer antara lain lebih akurat, menghemat waktu pengisian, sangat mudah dalam penggunaannya dan dokumen lebih berkualitas. Dokumentasi asuhan keperawatan paper based memiliki beberapa kelemahan antara lain rendahnya kualitas pencatatan, waktu pengisian formulir relatif lebih lama dan memerlukan ruang yang luas untuk penyimpanannya. Tujuan penelitian: Mendeskripsikan gambaran kebutuhan rencana pengembangan dokumentasi asuhan keperawatan elektronik di RSKD Balikpapan ditinjau dari aspek human, organisasi, dan teknologi. Metode penelitian: menggunakan mixed method yaitu campuran antara metode kuantitatif dan metode kualitatif. Hasil penelitian : Saat ini di RSKD sudah memungkinkan untuk diterapkan dokumentasi asuhan keperawatan elektronik. Berdasarkan variabel SDM: persepsi, motivasi, mayoritas responden mendukung meskipun perilaku dalam menuliskan dokumentasi keperawatan masih belum baik. Variabel Organisasi : komitmen, lingkungan kerja, mendukung penerapan dokumentasi keperawatan elektronik. Variabel teknologi : dibutuhkan 2 unit komputer untuk tiap ruangan perawatan, menginginkan agar membangun sendiri aplikasi yang akan digunakan. Kesimpulan : Perawat di RSKD memiliki persepsi, motivasi yang baik untuk pengembangan dokumentasi keperawatan elektronik meskipun perilaku perawat dalam mengisi dokumentasi keperawatan belum baik. Komitmen pimpinan dan staff, lingkungan kerja di RSKD memungkinkan untuk diterapkan dokumentasi asuhan keperawatan elektronik. Diperlukan minimal 2 unit perangkat komputer disetiap ruangan, dan aplikasi yang digunakan sebaiknya dibuat sendiri disesuaikan dengan standar yang terapkan di RSKD Balikpapan. Kerangka HOT-FIT juga dapat digunakan untuk mengidentifikasi kebutuhan pengembangan sistem informasi.

Background: Nursing documentation is sequence of activity which performed by nurse, started from assessment, diagnose, action plan, nursing action and evaluation, which could be transcript both in electronic and manual as well as could be accountable. Compared to the paper based, electronic documentation is faster, in time, and more clear in provide an information from the provided action. The advantage of computer utilization among others is more accurate, save the filling time, very easy in the using and the document is more quality. Paper based nursing document, had several disadvantage, such as; poor transcript accurate, more time to filling a form and need wider room to keep the documents. Objectives: To describe the depiction of the need on development plan of electronic nursing documentation at Dr. Kanujoso Djatiwibowo Hospital, Balikpapan, considered from human, organization and technological aspects. Methods: The research was using mixed methods, that were the mix between quantitative and qualitative methods. Results: Today, at Dr. Kanujoso Djatiwibowo Hospital, was possible to implement electronic nursing care documentations. Based on human resources variables: perception, motivation, majority supported although the behavior in transcribe a nursing documentation was not follow the desired yet. Organization variables: commitment, work environment, majority supported. Technological variables: it was need 2 unit computers for each nursing room, desired to build by their own self the application would used. Conclusions: Nurses at Dr. Kanujoso Djatiwibowo Hospital had good perception and motivation to developing electronic nursing documentation, although their behavior in filling the nursing documentation not good yet. The commitment from the leader and staff, work environment in Dr. Kanujoso Djatiwibowo Hospital, enable for implementation of electronic nursing documentation. Its need at least 2 computer in each room, and the used application advisable was made by their self and appropriated with the prevailing standard in the hospital. HOT-FIT frame also can be used to identifying the need to developing an information system.

Kata Kunci : analisis kebutuhan, dokumentasi asuhan keperawatan, dokumentasi keperawatan elektronik.