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ANALISIS PROSES PENDOKUMENTASIAN ASUHAN KEPERAWATAN
DI RUANG RAWAT INAP RUMAH SAKIT JIWA PROVINSI ACEH
ANALYSIS OF NURSING CARE DOCUMENTATION PROCESS
AT INPATIENT WARD OF ACEH MENTAL HOSPITAL
Abdul Aziz1, Andreasta Meliala2
ABSTRACT
Background: Nursing documentation as a component of hospital
information system is essential to do in the hospital. At Aceh Mental
Hospital, the process of nursing care documentation has not been
practised appropriately; thus accuracy and completeness of data cannot
be well utilized.
Objective: The study aimed to analyze the process of nursing care
documentation, completeness of nursing documentation and factors
influencing the process of nursing documentation at inpatient ward of Aceh
Mental Hospital.
Method: This descriptive study used qualitative method. Data were
obtained through indepth interview and observation of nursing
documentation records.
Result: Completion of nursing documentation form at inpatient ward of
Aceh Mental Hospital was 49.07%. Characteristics of nurses had no
significant association with completeness of nursing care documentation.
There was no accuracy of data in nursing care documentation records and
completion of nursing care documentation was not made soon after there
was nursing intervention. Some factors that influenced nurses in the
process of nursing care documentation at inpatient ward of Aceh Mental
Hospital were unsystematic form of documentation, lack of training, less
optimum monitoring, lack of motivation, lack of knowledge and
competence of nurses, overload work, limited time, and absence of solid
reward and punishment system as well as undecisive attitude of the leader
in the implementation of nursing care recording.
Conclusion: Nursing records made by nurses at inpatient ward of Aceh
Mental Hospital had not fully described accurately about the condition and
nursing intervention given to the patient so that the function of nursing
records had not been well utilized.
Keywords: nursing care documentation, mental hospital, hospital
information system
1.
Mental Hospital, Province of Aceh
Program in Hospital Management, Faculty of Medicine, Gadjah
Mada University
2. Graduate
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PRELIMINARY
The existance of integrated health information system and able to
give the data or information completely, accurately and timely is one of
very important element in making decision in health term. In the hospital,
implementation of health information system must be done entirely in all
treatment unit, also include in nursing care unit. In nursing practice, the
implementation of health information system mentioned in nursing
recorded application form.
The nursing documentation which is part of health record in
hospital must be made completely and accurately in order to be able to
used in making decision and evaluate health treatment quality are given 1.
Although in implementation, there be much unfilled nursing record sheet
are found. Some factors that influence of completeness in filling of nursing
record sheet are documentation form, supervision, timing needed to
record, training, and burden of work 2.
Aceh Mental Hospital as one of institution are held the nursing
treatment obligate to provide the nursing care documentation. The
implementation of recording must be done as soon as possible after
nursing intervention done and contain of data or accurate information that
recorded completely, clearly and readable.
Related to the case above some of problems are related to the
implementation of nursing record process in Aceh Mental Hospital are still
low of completeness level of filling nursing record sheet, recorded was
done in unright time and the accuracy data recorded in nursing record
sheet are pretended.
Based on statement above, the researcher interest to reseach in
Aceh Mental Hospital further to identify the completeness of filling the
nursing record sheet, the process implementation of nursing record and to
identify any factors that influence the completeness of filling the nursing
record sheet in the inpatient ward of Aceh Mental Hospital.
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RESEARCH METHODE
This research is a descriptive study with explorative characteristic
by using qualitative research methode. Data collecting process was done
by indepth interview and observation to arcipt of nursing care record. The
unalysis unit in this research are 3 inpatient wards with different
characteristic. The difference are on the amount of nurse-patient
proportion and the carateristic of patient. The inpatient ward that be
selected are 1 inpatient ward with nurse-patient proportion is 1:2 with acut
patient condition (Seurune), 1 inpatient ward with nurse–patient proportion
is 1:1 and cooperative patient condition (Dahlia) and 1 inpatient ward with
nurse–patient proportion is 1:4 and cooperative patient condition (Mawar).
The difference of proportion of nurse –patient and characteristic of patient
causes the different things of burden of work was faced by each inpatient
ward.
Observation of completeness filling of nursing care documentation
was done for nursing record that have been returned to medical record
sub section. Nursing record was taken by randomly as much as 3 nursing
record in every nurse who works in the inpatient ward that becomed as
analysis unit in the research.
Indepth interview was done for subject research taken by using
purposive sampling technic. The subject of research are 6 persons of
nurse, 3 persons of head inpatient ward, a person of administration
section head are experted in nursing care and a person head of nursing.
RESULT AND DISCUSSION
1. Completeness of Nursing Documentation
Completeness of nursing care documentaion are evaluated based
on filling the items that must be filled or available in nursing care
documentation sheet. Nursing record that analyzed is nursing assessment
and diagnose sheet and sheet of progress notes (implementation and
evaluation). In nursing assessment sheet, amount of the item that
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analyzed as much as 42 items, in nursing diagnose sheet as much as 2
items and in progress notes sheet as much as 13 items.
The analysis of completeness of filling nursing record sheet have
done by using check list observation which is developed by researcher
that available to nursing care documentation form that used in
Aceh
Mental Hospital. The amount of nursing record that analyzed is as much
as 102 was made by the nurse in the inpatient ward of Mawar, Seurune
and Dahlia in Aceh Mental Hospital.
The recapitulation result of evaluated the completeness of filling
nursing record sheet of 3 inpatient ward was shown on table 1.
Table 1
The Recapitulation Result of Completeness of Filling Nursing Record
Sheet in Mawar, Seurune, and Dahlia Inpatient Ward in Aceh Mental
Hospital
No
1.
2.
3.
4.
Inpatient Unit
Mawar
Seurune
Dahlia
Amount
% Amount % Amount
%
Nursing Assessment
732
48,41
686
49,49
745
53,75
Nursing Diagnose
56
77,77
50
75,75
52
78,78
Planning
0
0,00
0
0,00
0
0,00
Progress Notes
388
82,90
368
85,78
377
87,87
(Impl + Evaluation)
Total
1176
47,34
1104
48,48 1174
51,55
Evaluated Aspect
Based on the table 1 can be seen that level achievement of
completeness of filling nursing record sheet in every inpatient ward starts
from the higher as follows: Dahlia (51,55%), Seurune (48,48%), and
Mawar (47,34%). The result shown that the level of completeness in filling
nursing record sheet in each inpatient ward of Aceh Mental Hospital is still
low.
The total completeness of filling nursing care documentation in the
inpatient ward (Mawar, Seurune and Dahlia) of Aceh Mental Hospital is
shown on table 2
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Table 2
The Total Completeness of Filling Nursing Record Sheet in The Inpatient
Ward (Mawar, Seurune and Dahlia) of Aceh Mental Hospital
No
1.
2.
3.
4.
Evaluated Aspect
Nursing Assessment
Nursing Diagnose
Planning
Progress Notes
(Implementation + Evaluation)
Total
Amount
2163
158
0
1133
Percentage (%)
50,49
77,45
0,00
85,44
3454
49,07
Based on the table 2 can be seen that generally the completeness
of filling nursing care documentation form in the inpatient ward of Aceh
Mental Hospital is still low as much as 49,07% . Planning aspect is the
most low on value of completeness as much as 0,00%. This caused on
observation unfound the form of planning record, so that the planning
unmade by the nurse, whereas the planning of nursing intervention is one
of must focus element on nursing care documenting 3.
The result of analysis through filling of nursing assessment sheet,
the value of completeness was earned is still low. This one caused of
nursing assessment sheet is too much items that must be filled by nurse
and sometimes they are not understood the meaning of the item so that
most of items are unfilled.
In this research, to know the relation of respondent characteristic
by the completeness of filling nursing care record sheet include statistic
test by using T test. The result of the statistic test as shown on table 3 as
below.
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Tabel 3
Respondent Characteristic Crosstab With The Completeness Of Nursing
Care Documentation
No.
1.
2.
3.
4.
5.
The Completeness of Nursing Care
Document
Mean
Std deviasi
T
P
Respondent
Characteristic
Gender
- Male
- Female
Age
- 20-29 year
- > 29 year
Education
- Academic
- Sarjana Degree
Time of working
- 1-5 year
- > 5 year
Employee Status
- PNS
- Non PNS
101,68
101,33
6,14
5,33
0,14
0,88
101,22
102,00
5,74
6,15
0,38
0,70
100,78
102,60
4,19
7,50
0,89
0,37
100,77
102,50
4,83
6,88
0,85
0,40
101,59
101,58
6,73
4,05
0,00
0,99
Based on the table 3 can be seen that the whole element of
respondent characteristic earned thitung< ttabel (t<2,04) and p>0,05. It shown
that characteristic of nurse in the inpatient ward of Aceh Mental Hospital
has not significance related to the completeness of filling nursing care
documentation form.
The completeness of filling nursing care documentation absolute
needed. The failure to provide the complete dan accurate nursing record
means that the failure of doing task to the patient, family, and people 4.
Besides
that,
the
completeness
of
filling
nursing
care
documentation are useful to protect the nurse from accusation the law,
where the malpraktik pursuit, nursing record can be able to be an evidence
of nursing intervention are given and the nurse could defend the right
information by using the nursing record 5.
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2. Process of Nursing Care Record
As known as the process of nursing record was done when patient
in admission untill home. Process of nursing care record was done by
continually as long as still get the treatment in hospital. Every nursing
intervention to the patient it must be made documenting in nursing record
sheet in the medical patient record file.
Related to implementation of nursing record in the inpatient ward
of Aceh Mental Hospital, the result of observation and interview with the
nurse was known that not all nursing intervention are made recording on
documenting sheet. In nursing treatment is supposed to every intervention
is documented completely and accurate as an evidence to implementation
of nursing treatment activities 6.
Nursing record as an evidence to implementation of nursing
practice must be made completely and accurate and directly record after
nursing intervention are given to the patient. Related to implementation of
process nursing record in the inpatient ward of Aceh Mental Hospital,
based on the result of interview and observation, it was earned information
that in the inpatient ward of Aceh Mental Hospital still found the nursing
record that contain unaccurate data or information, where the nursing care
record was made unavailable with condition or intervention that was done
to the patient. Besides that, in the inpatient ward of Aceh Mental Hospital
found the process of filling nursing record sheet which is indirectly filled
after nursing intervention done, but filling of nursing record sheet just be
filled or to be completed when the patient moved on other treatment room
or when the patient would home.
The other problem that found related to implementation of process
nursing record in Aceh Mental Hospital, there be no a standar prosedure
of nursing record implementation process, whereas the standard
prosedure absolutely needed as the guidelines for nurse in documenting
so that nursing record could be resulted much better and directed 7.
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3. Factors Influence of process Nursing Care Documenting
Incompletely
filling
form
of
nursing
documentation
and
implementation of nursing record process which unavailable to expectation
in the inpatient ward of Aceh Mental Hospital was caused by many factors.
One of causes factor is unsystematic nursing documentation form design.
Based on the result of interview with the nurse may earned the
information that documentation form design for nursing assessment aspect
and nursing diagnose in the inpatient ward of Aceh Mental Hospital
systematically enough and easy to be filled because only checklist left in
providable item. However, many items are provided in nursing assessment
sheet that must be filled become a complaint often uttered. So many items
that must be filled in nursing assessment sheet, it caused saturation and it
run off so much time in process of filling. Besides, the result of interview
was known that some items in nursing assessment sheet are less to be
understood by the nurse, so that the item are blanked by the nurse when it
was recorded. The hospital must be limited amount of nursing asessment sheet
there be more brieftly, clear, and focus to ease evaluating treatment 8
Whereas for sheet of progress notes (implementation and
evaluating), according to the information of the nurse, form which is used
unsystematic. Form for progress notes are blank table and must be filled
by the nurse writing much in the sheet provided. This case causes the
nurse run off the time to record then finally feel saturated and lack of
motivation to make nursing record.
Besides the factor of nursing documentation form design are
unsystematic, some factors that influence the nurse in implementation of
process nursing record in the inpatient ward of Aceh Mental Hospital is
that lack of training, unoptimum supervision, overload work, lack of
motivation and competence of the nurse, absence of solid reward and
punishment system, time limit, the unused nursing record, lack of support
from the partner and undecisive attitude of leader in the implementation of
nursing care recording.
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4. Policy of Nursing Manager
Nursing manager as a leader of the nurse must have skillness in
leading and be able to influence the nurse to implementation the task and
responsible of determined goal achievement. Therefore, a nursing
manager asked to be able to do the function and the duty as a leader in
nursing unit is leaded. If based on oriented function and task, so the leader
activity gives direction, supervision, coordination and motivation 9.
Related to the implementation of nursing care recording in Aceh
Mental Hospital, based on the result of interview was known that the policy
of nursing manager had done to increase the quality of nursing record is
only implementate the function of direction, where the manager of nursing
only give the direction and support to the nurse to do the best record.
Meanwhile, supervision function, coordination and giving motivation are
not implementate good. In this case unoptimum supervision have done by
the nursing manager, there be no training for nurse to increase the
skillness in implementate of recorded and there be no giving reward and
punishment by nursing manager as one of stimuly of increasing motivation
of nurse in making nursing record.
Direction are given by nursing manager proved uneffectively
enough to increase the quality of nursing record in the inpatient ward of
Aceh Mental Hospital. This realized from the result of study completeness
of filling nursing record sheet still low. Direction and support uneffectively
might caused by the direction was given to nurse with no controlling and
training and there be no effort to increase nurse motivation through giving
reward and punishment are appropiate aimed.
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CONCLUSION
1. The completeness of filling the nursing record sheet in the inpatient
ward of Aceh Mental Hospital is still low. It’s about 49.07%. It shows
that nurse is not make the best yet in recording process in nursing
form record.
2. Nursing recording process in the inpatient ward of Aceh Mental
Hospital is not running well yet where is still found the completion of
nursing care documentation was not made soon after there was
nursing intervention. Besides that, unaccurate of the recorded data in
the nursing form record is often appear.
3. The uncompleteness of nursing care documentation and the recording
process that is not entirely realized well yet because of many factors.
The factors are unsystematic documentation form design, lack of
training, unoptimum supervision, overload work, and lackness of nurse
motivation and competence in recording process.
4. Policy and effort from the nursing manager to increase quality of
nursing record in Aceh Mental Hospital is not optimum.
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