PENGARUH SUPERVISI KEPALA RUANGAN TERHADAP PELAKSANAAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUANG RAWAT INAP RSU AISYIYAH PADANG TAHUN 2018

Abstract

ABSTRAK

Supervisi dalam pelaksanaan pendokumentasian asuhan keperawatan di RSU ‘Aisyiyah Padang didapatkan data berdasarkan hasil pengamatan medical record di ambil 40 sampel dokumentasi rekam medik pasien rawat inap, hanya 21 dokumen (42%) yang dokumentasi asuhan keperawatan terisi lengkap,19 dokumen (58%) di isi tidak lengkap. Berdasarkan wawancara dengan kepala Instalasi Rawat Inap mengenai kegiatan supervisi kepala ruang tentang dokumentasi asuhan keperawatan, diperoleh informasi bahwa selama ini kepala ruangan melakukan supervisi sekali sebulan. Penelitian ini bertujuan untuk mengetahui Pengaruh Supervisi Kepala Ruangan Terhadap Pelaksanaan Pendokumentasian Asuhan Keperawatan di Ruang Rawat  Inap RSU ‘Aisyiyah Padang Tahun 2018.

Jenis penelitian adalah Pre-eksperimental design yang bertujuan melihat ada tidaknya “Pengaruh Supervisi Kepala Ruangan Terhadap Pelaksanaan Pendokumentasian Asuhan Keperawatan di Ruang Rawat  Inap RSU ‘Aisyiyah Padang Tahun 2018”, dengan rancangan yang digunakan One Group pretest–Postest Design. Dengan jumlah sampel 12 orang dengan teknik total sampling. Analisa data diolah menggunakan univariat ditampilkan dalam bentuk tabel distribusi frekuensi dan analisa bivariat uji statistik yang digunakan uji statistik Paired T-test dengan p value (0,05)

Hasil penelitian terdapat perbedaan pendokumentasian asuhan keperawatan sebelum dan sesudah diberikan supervisi, dimana rata-rata pendokumentasian asuhan keperawatan sebelum diberikan supervisi 34,56 standar deviasi 4,912 yaitu tergolong tidak lengkap. Sesudah diberikan supervisi rata-rata pendokumentasian asuhan keperawatan menjadi 28,38 dengan standar deviasi 4,773 atau tergolong lengkap. Berdasarkan hasil uji statistik didapatkan P value = 0,000, maka dapat disimpulkan terdapat pengaruh supervisi dalam meningkatkan pendokumentasian asuhan keperawatan.

Terdapat pengaruh supervisi kepala ruangan dengan pelaksaan pendokumentasian asuhan keperawatan. Dianjurkan pada kepala ruangan untuk melaksanakan supervisi secara berkala dan melakukan monitoring dengan baik.

Kata kunci : Supervisi , Pendokumentasian Asuhan Keperawatan

 

ABSTRACT

Supervision in the implementation of documentation of nursing care at RSU 'Aisyiyah Padang obtained data based on medical record observations taken 40 documentation samples of medical records of inpatients, only 21 documents (42%) with complete nursing care documentation, 19 documents (58%) in incomplete content. Based on the interview with the head of the Inpatient Installation regarding the supervision of the head of the room about nursing care documentation, information was obtained that so far the head of the room had supervised once a month. This study aims to determine the influence of the Supervision of the Head of the Room on the Implementation of Documentation of Nursing Care in the Inpatient Room of RSU 'Aisyiyah Padang in 2018.

This type of research is Pre-experimental design that aims to see whether there is a "Effect of Supervision of the Head of the Room on Documentation of Nursing Care in the Inpatient Room of RSU 'Aisyiyah Padang in 2018", with the design used by One Group pretest-Postest Design. With a sample of 12 people with total sampling technique. Analysis of data processed using univariate is displayed in the form of frequency distribution tables and bivariate analysis statistical tests used statistical tests Paired T-test with p value (0.05)

The results of the study there are differences in documenting nursing care before and after supervision, where the average documentation of nursing care before being given supervision 34.56 standard deviation 4,912 is classified as incomplete. After being supervised on average, documenting nursing care became 28.38 with a standard deviation of 4,773 or complete. Based on the results of statistical tests obtained P value = 0,000, it can be concluded that there is an influence of supervision in improving documentation of nursing care.

               There is the influence of the supervision of the head of the room with the implementation of documenting nursing care. It is recommended to the head of the room to carry out periodic supervision and monitor properly.

Keywords: Supervision, Documentation of Nursing Care