PELATIHAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN MENINGKATKAN KELENGKAPAN DOKUMENTASI KEPERAWATAN

Nursing documentation in the form of document nursing care is one evidence of
responsibility and accountability for the actions of nurses during duty nursing services.
The training program documentation of nursing care should be given to both the nurses who have worked or who have been there to deal with situations that change, to be
trained in this documentation in the hope that the nurse who had worked at the hospital
knows how to fill in the correct and expected to be complete and nurses who have long
worked able to know if there is a changes in filling technique.
The research design used in this study is Preexperimental One Group Pre Post
Test Design. The studied population of 16 respondents in the room Adults and Children
space PKU Muhammadiyah Hospital Sekapuk. Total sampling obtained 16 samples of the
study. Instruments used in the form of SAP and observation sheet. Analysis using
statistical tests Wilxocon Signed Rank Test with significance level α < 0.05.
The result showed there was an increasing completeness of documentation in
nursing from the previous complete enough to be complete. The statistical test obtained
value ρ = 0.00 < 0.05 mean H0 rejected and H1 accepted meaning there was of effect
training on the completeness nursing documentation.
Nurses can apply nursing documentation filling completely to maintain the
quality of nursing care. Hospital leaders can conduct regular training,every new nurse
orientation or senior nurse.