EVALUASI PENERAPAN FORMAT DOKUMENTASI KEPERAWATAN MODEL CHECKLIST DI RSUD BANJARBARU KALIMANTAN SELATAN
Muhammad Hadarani, Dr. Fitri Haryanti, SKp., M.Kes.
2013 | Tesis | S2 Ilmu Kesehatan MasyarakatLatar belakang: Rendahnya kelengkapan pendokumentasian asuhan keperawatan yaitu sebesar 54,29%, merupakan suatu permasalahan diunit rawat inap RSUD Banjarbaru. Solusi yang dilaksanakan RSUD Banjarbaru untuk mengatasi masalah tersebut dengan menerapkan format dokumentasi asuhan keperawatan model checklist. Efektivitas penerapan format pendokumentasian keperawatan model checklist tersebut masih perlu dievaluasi. Tujuan: Penelitian ini bertujuan mengevaluasi efektivitas hasil penerapan format dokumentasi keperawatan model checklist di unit rawat inap RSUD Banjarbaru. Metode: Jenis penelitian quasi eksperimental, dengan rancangan pre dan post test tanpa kontrol. Penelitian dilaksanakan diruang rawat inap penyakit dalam, bedah, anak dan ICU RSUD Banjarbaru dari tanggal 5 Juni 2012 sampai dengan 30 Juli 2012. Sampel penelitian sebelum penerapan format checklist sebanyak 230 rekam medis, sesudah penerapan format checklist sebanyak 230 rekam medis. Penelitian menggunakan lembar observasi untuk menilai kelengkapan pendokumentasian dan outcome asuhan keperawatan pada rekam medis. Sebanyak 20 perawat dilakukan wawancara dengan menggunakan pertanyaan wawancara terstruktur untuk mengetahui penerimaan perawat terhadap penerapan format pendokumentasian checklist. Data kuantitatif disajikan menggunakan analisa distribusi frekuensi, untuk mengetahui signifikasi perbedaan kenaikan hasil kelengkapan pendokumentasian dilakukan uji statistik independent-sample t-test dan untuk mengetahui signifikasi perbedaan kenaikan outcome asuhan keperawatan dilakukan uji statistik chi-square. Analisa data kualitatif disajikan dengan interpretasi hasil transkrip dan membuat narasinya. Hasil dan pembahasan: Hasil wawancara menunjukkan tanggapan dan sikap yang mendukung terhadap penerimaan penggunaan format pendokumentasian checklist. Hasil penelitian menunjukkan adanya peningkatan yang signifikan kelengkapan pendokumentasian asuhan keperawatan pada ruang rawat inap penyakit dalam, bedah, anak dan ICU RSUD Banjarbaru setelah penerapan format pendokumentasian checklist dari sebelumnya sebesar 54.0% (katagori kurang), menjadi 91.9% (katagori baik). Ada perbedaan yang signifikan outcome asuhan keperawatan setelah penerapan format checklist, dari sebelumnya outcome katagori baik hanya sebanyak 17.9%, menjadi outcome katagori baik sebanyak 73.5%. Kesimpulan: Penerapan format pendokumentasian keperawatan model checklist efektif meningkatan kelengkapan pendokumentasian keperawatan dan outcome asuhan keperawatan. Penerimaan perawat terhadap penerapan format pendokumentasian model checklist cukup baik.
Background: The low completeness of nursing care documentation that was at 54.29% was one of problem in inpatient unit of RSUD Banjarbaru. The solution that was performed by RSUD Banjarbaru to overcome the problem was by implementing the checklist model nursing care documentation form. There were several advantages and disadvantages in this form so it was need to perform evaluation to the result of an implementation of the checklist model nursing care documentation form. Objectives: The study was aimed to evaluate the effectivity of the result of an implementation of the checklist model nursing documentation form in inpatient unit of RSUD Banjarbaru. Methods: This was quasi experimental study by pre and post test design without control. The study was performed in inpatient unit of internal disease ward, surgical ward, pediatric ward and ICU ward of RSUD Banjarbaru started in 5th June 2012 to 30th July 2012. The sample for the time before an implementation of checklist form was 230 medical records and for the time after implementation of checklist form were 230 medical records. The study was using observation sheets to assess the completeness of documentation and the outcome of nursing care in the medical record. About 20 nurses were interviewed by using structured questionnaire to knowing their acceptance to the implementation of checklist documentation form. The quantitative data was presented using frequency distribution analysis, to knowing the difference significance of the increasing of the documentation completeness result by independent sample t-test and to knowing the difference significance of the increasing of the nursing care outcome it was performed chi-square test. Qualitative data analysis was presented by interpretation of the transcription result and made their narration. Results and discussion: The result of an interview showed that the respond and attitude was supporting the acceptance of the checklist documentation form utilization. The result of the study showed that there was significant increasing of the completeness of the nursing care documentation in inpatient unit of internal disease ward, surgical ward, pediatric ward and ICU ward of RSUD Banjarbaru after an implementation of checklist documentation form from 54.0% before an implementation (belong to less category) become 91.9% (belong to good category). There was significant difference of the outcome of nursing care after implementation of checklist form as follow; before an implementation the outcome that belong to good category was only 17.9% become 73.5% after an implementation. Conclusion: The implementation of checklist model nursing care documentation form was effective to increase the completeness of nursing documentation completeness and nursing care outcome. The acceptance of the nurse to the implementation of checklist model documentation form was good enough.
Kata Kunci : Format dokumentasi keperawatan checklist, hasil pendokumentasian, outcome asuhan keperawatan
