Hubungan Fungsi Pengarahan dan Fungsi Pengawasan Kepala Ruangan dengan Kelengkapan Pendokumentasian Keperawatan di Ruang Rawat Inap RSIA Kemang Medical Care

The Relationship between the Direction Function and the Head of Room Supervision Function with the Completeness of Nursing Documentation in the Inpatient Room of RSIA Kemang Medical Care

Abstract

Introduction: The nursing documentation process is an important activity because it can be evidence that all nursing actions have been carried out professionally and legally, to protect clients (patients) as service recipients and nurses as service providers. Based on the existing phenomenon, there is still often incompleteness in documenting nursing care in health services in hospitals. The purpose of this study is to determine the management of the directing and supervision function of the head of the room with the completeness of nursing documentation in the inpatient room of RSIA Kemang Medical Care in 2022

Methods: This study aims to determine the management of the directing and supervision function of the head of the room with the completeness of nursing documentation in the inpatient room of RSIA Kemang Medical Care in 2022. This type of research is quantitative with a cross-sectional design. This research was carried out in the pediatric inpatient and surgery, maternity and perinatology rooms of RSIA Kemang Medical Care in January 2023. The sample was taken in total sampling with a population of 30 respondents. The statistical test used is the statistical test "Chi Square" with a 95% confidence level when α <0.05.

Results: The results of the study obtained P Value = 0.003 for the directing function and 0.001 for the supervisory function.

Discussion: Thus, the results of the study showed a relationship between the function of direction and supervision of the head of the room with the completeness of documenting nursing care in the inpatient room of RSIA Kemang Medical Care. The good and bad quality of nursing services depends on the management of the head of the room to the implementing nurse. The more routine direction and supervision carried out by the head of the room, the better the quality of nursing services, especially the writing of nursing care documentation. Suggestions from this study are expected to provide knowledge to improve the quality of nursing documentation and improve the quality of nursing care for patients.