Inhouse Training Dokumentasi Asuhan Keperawatan di Klinik Pratama Muhammadiyah Pringsewu

Fitra Pringgayuda

Sari


ABSTRAK

 

Keterbatasan perawat dalam melakukan dokuumentasi keperatan sesuai dengan standar masih menjadi masalah terutama di klinik pratama termasuk pada klinik Pratama PKU Muhammadiyah Pringsewu. Salah satu upaya untuk mengatasi hal tersebut adalah melakukan inhous training dokumentasi asuhan keperawatan. Tujuan untuk melakukan in house training dokumentasi asuhan keperawatan untuk meningkatkan keterampilan dokumentasi keperawatan. Kegiatan pengabdian kepada masyarakat (PKM) ini dilakukan di klinik pratama PKU Muhammadiyah Pringsewu yang melibatkan 15 orang perawat. Pelaksanaan dilakukan pada 1-5 Juli 2024. Kegiatan ini mulai dari refresh materi kemudian melakukan inhouse training dalam meningkatkan keterampilan dokumentasi asuhan keperawatan. Hasil dari PKM didapatkan peningkatan pengetahuan dari rerata 62,7% menjadi 87,1% (peningkatan 38,9%). Terdapat peningkatan keterampilan dari 57,9% menjadi 82,6% (peningkatan 42,6%). Kegiatan inhouse training dokumentasi asuhan perawatan efektif dalam meningkatkan keterampilan dokumentasi keperatan perawat, namun tetap diperlukan evaluasi jangka Panjang untuk kelanjutan.

 

Kata Kunci: Asuhan Keperawatan, Dokumentasi, Inhouse Training

 

ABSTRACT

 

The limitations of nurses in documenting nursing care according to standards is still a problem, especially in primary clinics including the PKU Muhammadiyah Pringsewu Primary Clinic. One effort to overcome this is to conduct in-house training on nursing care documentation. To conduct in-house training on nursing care documentation to improve nursing documentation skills. This community service activity (PKM) was carried out at the PKU Muhammadiyah Pringsewu Primary Clinic involving 15 nurses. The implementation was carried out on July 1-5, 2024. This activity started from refreshing the material then conducting in-house training in improving nursing care documentation skills. From PKM, there was an increase in knowledge from an average of 62.7% to 87.1% (an increase of 38.9%). There was an increase in skills from 57.9% to 82.6% (an increase of 42.6%). In-house training activities on nursing care documentation are effective in improving nurses' nursing documentation skills, but long-term evaluation is still needed for continuation.

 

Keywords: Nursing Care, Documentation, Inhouse Training.


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Referensi


Agustin, M., Idris, M., Seniwati, Istiqomah, Rapingah, S., & Pujiharti, I. (2022). Buku Ajar Dokumentasi Keperawatan. Zahir Publishing.

Awaliyani, V. A., Pranatha, A., & Wulan, N. (2021). Pengaruh Penggunaan Buku Sdki, Slki Dan Siki Terhadap Peningkatan Pengetahuan Perawat Dalam Membuat Dokumentasi Keperawatan Berbasis Sdki, Slki Dan Siki Di Rumah Sakit Kmc Kuningan Tahun 2021. Journal of Nursing Practice and Education, 2(1), 22–32. https://doi.org/10.34305/jnpe.v2i1.334

Batubara, K., & Sinaga, E. (2024). Dokumentasi Keperawatan. CV Mega Press Nusantara.

Hariyati, R. T. S., Hamid, A. Y., Eryando, T., & Hasibuan, Z. A. (2020). Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation at a hospital in Indonesia. International Journal of Healthcare Management, 13(1), 45–52. https://doi.org/10.1080/20479700.2018.1504387

Hylén, U., Engström, I., Engström, K., Pelto-Piri, V., & Anderzen-Carlsson, A. (2019). Providing Good Care in the Shadow of Violence – An Interview Study with Nursing Staff and Ward Managers in Psychiatric Inpatient Care in Sweden. Issues in Mental Health Nursing, 40(2), 148–157. https://doi.org/10.1080/01612840.2018.1496207

Jakobsson, J., Örmon, K., Berthelsen, H., & Axelsson, M. (2022). Workplace violence from the perspective of hospital ward managers in Sweden: A qualitative study. Journal of Nursing Management, 30(6), 1523–1529. https://doi.org/10.1111/jonm.13423

Kang, M.-J., Rossetti, S. C., Knaplund, C., Chang, F. Y., Schnock, K. O., Whalen, K., Gesner, E. J., Garcia, J. P., Cato, K. D., & Dykes, P. C. (2021). Nursing Documentation Variation Across Different Medical Facilities Within an Integrated Healthcare System. CIN: Computers, Informatics, Nursing, 39(12). https://journals.lww.com/cinjournal/fulltext/2021/12000/nursing_documentation_variation_across_different.3.aspx

Kartini, M., & Ratnawati, E. (2022). Efektivitas Pelatihan Dokumentasi Keperawatan terhadap Pengetahuan Perawat Mengenai SDKI, SLKI, dan SIKI. Jurnal Kesehatan, 11(1), 2721–8007.

Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. Journal of the American Medical Informatics Association, 28(5), 998–1008. https://doi.org/10.1093/jamia/ocaa325

Muzaenah, T., Yulistiani, M., Nurjanah, S., & Istianah. (2023). In House Training Upaya Peningkatan Kemampuan Perawat Dalam Memenuhi Kebutuhan Spiritual Care Pasien. Jurnal Inovasi Dan Pengabdian Masyarakat Indonesia, 2(1), 9–13. https://doi.org/10.26714/jipmi.v2i1.72

Myklebust, K. K., & Bjørkly, S. (2019). The quality and quantity of staff-patient interactions as recorded by staff. A registry study of nursing documentation in two inpatient mental health wards. BMC Psychiatry, 19(1), 251. https://doi.org/10.1186/s12888-019-2236-y

Nahak, M. P. M. (2023). Efektivitas Pelatihan Dokumentasi Keperawatan Menggunakan Panduan Teknis Terhadap Keterampilan Dokumentasi Keperawatan Pada Mahasiswa Keperawatan Universitas Timor. Jurnal Ilmiah Keperawatan (Scientific Journal of Nursing), 9(1), 130–139. https://doi.org/10.33023/jikep.v9i1.1388

Rahmatin, D. A., Dianah, H. S., & ... (2024). Sistem Dokumentasi Asuhan Keperawatan Dalam Upaya Peningkatan Mutu Manajemen Keperawatan. Jurnal Kesehatan Tambusai, 5, 1400–1409. http://journal.universitaspahlawan.ac.id/index.php/jkt/article/view/24369

Rahmi, U. (2023). Dokumentasi Keperawatan. Bumi Medika.

Risnah, R., Syisnawati, S., & Nurfadilah, S. N. (2023). Baby Blues Syndrome in Postpartum Mothers and Islamic Perspective : A Qualitative Study in Gowa , Indonesia Diversity : Disease Preventive of Research Integrity. Diversity: Disease Preventive of Research Integrity, 4(1), 118–130. https://doi.org/10.24252/diversity.v4i1.40634

Risnawati, Herman, A., Kurniawan, F., Shafwan, A., Harmanto, Njakatara, U. N., Armayani, Ardianto, Elmukhsinur, Andyka, Fidora, I., Halimah, & Perdana, S. (2023). Dokumentasi Keperawatan. CV.Eureka Media Aksara.

Shafiee, M., Shanbehzadeh, M., Nassari, Z., & Kazemi-Arpanahi, H. (2022). Development and evaluation of an electronic nursing documentation system. BMC Nursing, 21(1), 1–12. https://doi.org/10.1186/s12912-021-00790-1

Tasew, H., Mariye, T., & Teklay, G. (2019). Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Research Notes, 12(1), 1–6. https://doi.org/10.1186/s13104-019-4661-x

Trisno, T., Nursalam, N., & Triharini, M. (2020). Analysis of Accuracy Nursing Care Process Implementation. Jurnal Ners, 15(1 Special Issue), 436–439. https://doi.org/10.20473/jn.v15i1Sp.19784

Wahyuliati, T., & Regina VT Novita. (2023). Efektivitas Pelatihan dan Supervisi terhadap Peningkatan Kualitas Pendokumentasian Asuhan Keperawatan : Literature Review. Media Publikasi Promosi Kesehatan Indonesia (MPPKI), 6(7), 1250–1258. https://doi.org/10.56338/mppki.v6i7.3459




DOI: https://doi.org/10.33024/jkpm.v7i12.17599

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