PENDOKUMENTASIAN ASUHAN KEPERAWATAN OLEH PERAWAT PELAKSANA DI RUANG RAWAT INAP

Abstract: Nurses are required to document nursing care as a form of responsibility for providing care to patients. Good behavior is needed in writing nursing care documentation so that it is of high quality. This study aims to determine the behavior of nurses in the documentation of nursing care. The design of this research was descriptive analytic. The research variable was the behavior of documenting nursing care as measured by using a modified questionnaire from instrument A. The population was all nurses in the inpatient room at a private hospital in Surabaya. The sample size was 34 people obtained by total sampling technique. Analysis using descriptive analysis. In the nursing assessment stage, the majority of respondents had good behavior, namely 30 people (82%). Nursing diagnosis stage as many as 19 people (56%) have good behavior. The nursing intervention stage of the majority of respondents had good behavior as many as 32 people (94%). The nursing implementation stage for the majority of respondents had good behavior as many as 24 people (71%). The nursing evaluation stage for the majority of respondents had sufficient behavior as many as 26 people (76%). The behavior of documenting nursing care is good because it is a mandatory thing for nurses to do every day. The behavior of documenting nursing care by nurses is well implemented at every stage of the nursing care process. Keywords: behaviour, documentation, nursing care, nurse Abstrak: Perawat dituntut untuk melakukan pendokumentasian asuhan keperawatan sebagai bentuk tanggung jawab terhadap pemberian asuhan kepada pasien. Diperlukan suatu perilaku yang baik dalam menulis pendokumentasian asuhan keperawatan agar bermutu. Penelitian ini bertujuan untuk mengetahui perilaku perawat dalam pendokumentasian asuhan keperawatan. Desain penelitian ini adalah deskriptif analitik. Variabel penelitian yaitu perilaku pendokumentasian asuhan keperawatan yang diukur dengan menggunakan kuesioner modifikasi dari instrumen A. Populasi adalah seluruh perawat di ruang rawat inap di salah satu rumah sakit swasta di kota Surabaya. Besar sampel sebanyak 34 orang yang didapatkan dengan teknik total sampling. Analisis menggunakan analisis deskriptif. Tahap pengkajian keperawatan mayoritas responden memiliki perilaku baik yaitu sebanyak 30 orang (82%). Tahap diagnosa keperawatan sebanyak 19 orang (56%) memiliki perilaku yang baik. Tahap intervensi keperawatan mayoritas responden memiliki perilaku baik sebanyak 32 orang (94%). Tahap implementasi keperawatan mayoritas responden memiliki perilaku baik sebanyak 24 orang (71%). Tahap evaluasi keperawatan mayoritas responden memiliki perilaku cukup sebanyak 26 orang (76%). Perilaku pendokumentasian asuhan keperawatan baik karena merupakan hal wajib yang dilakukan perawat sehari-hari. Perilaku pendokumentasian asuhan keperawatan oleh perawat pelaksanan baik pada setiap tahap proses asuhan keperawatan. Kata kunci: asuhan keperawatan, dokumentasi, perawat, perilaku