Search Repository Universitas Fort De Kock

Pendokumentasian asuhan keperawatan sangat penting namun implementasinya sering kali diabaikan, kelengkapan, ketepatan, kualitas dan relevansi antarproses keperawatan. Cara yang dilakukan untuk mengatasi ketidaklengkapan dokumentasi asuhan keperawatan adalah dengan penerapan Model Praktik Keperawatan Profesional (MPKP), diantaranya metode kasus. Hasil wawancara dengan kepala ruangan ICU RSUD Lubuk Sikaping diketahui bahwa dokumentasi lengkap hanya untuk catatan keperawatan dan kardek (kartu dokumentasi khusus ICU, tapi untuk pengkajian asuhan masih kurang. Observasi terhadap 20 status di ruang ICU hanya ditemukan 60 % dokumentasi yang lengkap. Penelitian ini bertujuan untuk mengetahui pengaruh penerapan metode kasus terhadap pendokumentasian asuhan keperawatan. Desain penelitian Quasi-eksperimen dengan pendekatan one group pretest postest design. Penelitian telah dilakukan di ruang rawat ICU RSUD Lubuk Sikaping pada bulan Desember 2018. Populasi adalah status pasien yang terdapat di RSUD Lubuk Sikaping, dengan rata-rata 22 status per bulan, dengan pengambilan sampel secara purposive sampling sebanyak 16 sampel. Data di kumpulkan dengan menggunakan lembar observasi dokumentasi keperawatan, kemudian diolah dan dianalisa secara komputerisasi menggunakan uji statistik t-dependent. Hasil analisa univariat diketahui rata-rata kelengkapan pendokumentasian asuhan keperawatan sebelum penerapan metode kasus adalah 12,95 (58,9%) dan setelah penerapan metode kasus adalah 18,5 (84,1 %). Hasil bivariat ada pengaruh penerapan metode kasus terhadap pendokumentasian asuhan keperawatan (p = 0,0005). Disimpulkan bahwa penerapan metode kasus berpengaruh terhadap pendokumentasian asuhan keperawatan. Diharapkan pada manajemen Rumah Sakit agar dapat membuat aturan/ SOP tentang penerapan metode kasus dalam pemberian asuhan keperawatan pada pasien di ruang intensif khususnya ruang ICU.

Documentation of nursing care is very important but its implementation is often overlooked, the completeness, accuracy, quality and relevance of the nursing process. The way to overcome the incompleteness of nursing care documentation is by applying the Professional Nursing Practice Model (MPKP), including the case method. The results of interviews with the head of the ICU room at Lubuk Sikaping Regional Hospital revealed that complete documentation was only for nursing and kardek records (ICU specific documentation cards, but for nursing studies were lacking. Observation of 20 statuses in the ICU only found 60% of complete documentation. to determine the effect of applying the case method to documenting nursing care. Research design Quasi-experimental with one group pretest posttest approach. The study was carried out in the ICU Hospital Lubuk Sikaping Hospital in December 2018. The population was the patient status in Lubuk Sikaping Hospital, with an average of 22 statuses per month, with purposive sampling as many as 16 samples. Data was collected using observation sheets of nursing documentation, then processed and analyzed computerically using t-dependent statistical tests. The results of the univariate analysis revealed that the average completeness of the documentation of nursing care before the application of the case method was 12.95 (58.9%) and after the application of the case method was 18.5 (84.1%). Bivariate results have the effect of applying the case method to documenting nursing care (p = 0,0005). It was concluded that the application of the case method had an effect on the documentation of nursing care. It is expected that in the management of the Hospital to be able to make rules / SOPs about the application of case methods in the provision of nursing care to patients in intensive space, especially the ICU.