Jurnal
Pelaksanaan Dokumentasi Asuhan Keperawatan Di Ruang Rawat Inap Rumah Sakit X Jakarta: Pilot Study
The quality of nursing documentation demonstrates the accountability of nurses in providing nursing care to patients. However, the implementation of nursing documentation at hospital X is 58% still below the standard so that it is necessary to optimize the implementation of nursing documentation. The purpose of this study is to describe an innovation project to optimize the implementation of nursing documentation. The method used was a pilot study of 70 nursing documentation. The process starts from problem identification, problem analysis, plan of action, implementation, and evaluation. The quality of nursing documentation is measured using a nursing documentation audit instrument. Implementation in the form of guidelines, standart operational procedure (SOP), socialization, trials, assistance and making video roleplay nursing documentation. The results of the study showed an increase in the implementation of nursing documentation by 11.40%. The conclusion is that the implementation of an innovation project can improve the implementation of nursing documentation. The recommendation is to use a guide, SOP and roleplay videos as a reference in carrying out nursing documentation.
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