ABSTRAKPendokumentasian asuhan keperawatan merupakan salah satu indikator penilaian kinerja perawat di rumah sakit. Tujuan penelitian untuk mengeksplorasi secara mendalam hambatan pendokumentasian asuhan keperawatan di ruang perawatan umum RSPAD Gatot Soebroto Ditkesad. Jenis penelitian kualitatif dengan pendekatan fenomenologi deskriptif melalui teknik wawancara mendalam.Hasil penelitian terkait hambatan pendokumentasian asuhan keperawatan diperoleh tujuh tema, yaitu: persepsi, respon, proses pengisian, kendala yang dihadapi, upaya yang dilakukan untuk mengatasi kendala, harapan perawat terhadap pendokumentasian asuhan keperawatan, dampak dari kendala-kendala yang dihadapi terhadap kinerja perawat. Kesimpulan, perlu pengarahan yang kontinyu dari organisasi agar pendokumentasian berjalan baik. Rekomendasi pelaksanaan supervisi dari manajemen keperawatan.

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ABSTRACT

Documentation of nursing care is one indicator of the performance assessment nurse at the hospital. Research goals to explore in depth the barriers documenting nursing care in general ward in Central Army Hospital Gatot Subroto Ditkesad. Qualitative research with descriptive phenomenological approach through indepth interview techniques.

The results related barriers to nursing documentation obtained seven themes, namely: perception, response, the charging process, the obstacles encountered, the efforts made to overcome the obstacles, expectations of nurses to nursing care documentation, the impact of the constraints faced by the performance of nurses. Conclusions, which need continuous guidance from the organization to running well documentation. Recommendations on the implementation of supervision of nursing management.