Dokumentasi keperawatan merupakan bentuk profesionalisme perawat. Kelengkapan dokumentasi diperlukan dalam menjamin kualitas asuhan keperawatan yang diberikan. Tujuan riset untuk identifikasi pengaruh penerapan SIMPRO terhadap kelengkapan dan aspek legal dokumentasi asuhan keperawatan. Metode penelitian kuantitatif dengan rancangan quasi experiment, pretest-posttest designs with comparison group. Sampel penelitian 68 dokumentasi asuhan keperawatan. Hasil menunjukkan peningkatan kelengkapan dokumentasi asuhan keperawatan sebesar 10,39 % setelah diterapkan SIMPRO (p = 0,0001), ada perbedaan kelengkapan dan aspek legal dokumentasi asuhan keperawatan antara kelompok intervensi dan kelompok kontrol setelah penerapan SIMPRO (p = 0,0001). Penerapan SIMPRO perlu memperhatikan kesiapan perawat, dukungan manajemen, dukungan IT dan teknologi komputer yang baik. Rekomendasi bagi pihak manajemen untuk monitoring rutin pelaksanaan dokumentasi asuhan keperawatan sebagai proses evaluasi dokumentasi dan penggunaan bahasa terstandarisasi dalam dokumentasi keperawatan.

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Nursing documentation is a part of nurses’ professionalism. Document completeness is needed to reassuring the quality of nursing care given. The purpose of this research was to identify the influence of SIMPRO application towards completeness and legal aspect of nursing care documentation.

The method was quantitative research with quasi experiment, pretest -posttest designs with comparison group. The sample of this research was 68 nursing care documentations.

After applying SIMPRO, it has showed 10, 39% of increase in nursing care documentations completeness (p = 0, 0001). In addition, there were differences of completeness and legal aspects of nursing care documentation between intervention group and control group (p = 0, 0001). Therefore, we could conclude that, to apply SIMPRO we need to observe the nurses’ readiness, managerial encouragement, also proper technology and computer support.

Finally, we recommends to the managerial level of the Hospital to make a routine monitoring of nursing care documentation implementation as evaluation process of documentation and the usage of standardized language in nursing documentations.