Gambaran Aplikasi Dokumentasi Asuhan Keperawatan Di Rumah Sakit Ortopedi Surakarta (Description of Nursing Care Documentation Application at Surakarta Orthopedic Hospital)

Jannah, Zulfa Fairuz and , Arum Pratiwi, S.Kp., M.Kes., Ph.D (2023) Gambaran Aplikasi Dokumentasi Asuhan Keperawatan Di Rumah Sakit Ortopedi Surakarta (Description of Nursing Care Documentation Application at Surakarta Orthopedic Hospital). Skripsi thesis, Universitas Muhammadiyah Surakarta.

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Abstract

One of the most important aspects in the evidence of nursing care is nursing documentation because it serves as a legal aspect in the field of nursing. Nursing care documentation can be manual or electronic writing that includes all the client's conditions or previously provided services. This study aims to find out an overview of the application of nursing care documentation at the Orthopedic Hospital Prof. Dr. R. Soeharso Surakarta conducted research from December - January. This type of research is quantitative research with a narrative descriptive research design. This research was conducted at Prof. Orthopedic Hospital. Dr. R. Soeharso Surakarta. Respondents in this study were conducted in 4 wards and 47 medical records. The sample strategy used was Accidental Sampling with extraction reacting to medical records which were filled out by nurses when the research was carried out. Data collection using demographic data questionnaires and nursing care observation sheets. The results showed that nursing documentation with the highest score in the incomplete category had the highest score in assessment with a percentage of 9.7%, then the complete category had the highest score for Diagnosis with a percentage of 74.2% and the last category Very Complete, the highest score in Implementation with a percentage of 33.9%. This study shows that the completeness of nursing care documentation at Prof. Orthopedic Hospital. Dr. R. Soeharso Surakarta which includes assessment, diagnosis, intervention, implementation and evaluation is included in the complete category.

Item Type:	Thesis (Skripsi)
Uncontrolled Keywords:	Application, Nursing care, Documentation
Subjects:	R Medicine > RT Nursing
Divisions:	Fakultas Ilmu Kesehatan > Keperawatan
Depositing User:	ZULFA FAIRUZ JANNAH
Date Deposited:	11 May 2023 06:32
Last Modified:	11 May 2023 06:32
URI:	http://eprints.ums.ac.id/id/eprint/111528

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