Kelengkapan pendokumentasian asuhan keperawatan merupakan bagian dari kualitas pelayanan keperawatan di rumah sakit. Pelaksanaan pendokumentasian adalah indikator kinerja perawat yang dipengaruhi oleh karakteristik dan beban kerja perawat. Penelitian ini bertujuan untuk mengidentifikasi hubungan antara karakteristik, beban kerja perawat dan kelengkapan pendokumentasian asuhan keperawatan di Ruang Umum Instalasi Rawat Inap RS. Desain penelitian ini adalah analitik observasional dengan pendekatan retrospective yang dilakukan pada tiga ruang rawat inap. Pengukuran kelengkapan dokumentasi menggunakan instrumen A Depkes dengan sampel 95 dokumen. Pengukuran beban kerja menggunakan teknik continous observation dengan sampel 46 perawat.
Hasil penelitian menunjukkan bahwa pendokumentasian rerata belum lengkap (71,6%), dan beban kerja perawat sebagian besar tinggi (52,2%). Faktor yang paling dominan memengaruhi kelengkapan pendokumentasian adalah pelatihan dan beban kerja. Ada hubungan antara masa kerja, pelatihan dan beban kerja dengan kelengkapan pendokumentasian. Direkomendasikan untuk pelatihan pendokumentasian bagi perawat dan meninjau ulang jumlah perawat serta penempatan tenaga sesuai dengan beban kerja di ruangan.
Factors Related to the Completeness of Nursing Documentation. The completeness of nursing documentation is one of indicators in hospital service quality. Nursing documentation is an indicator of nurses performance that influenced by nurses?characteristics and workload. This study aimed to find out the relationship between nurses? characteristics and workload with the completeness of nursing documentation in wards. This study was a retrospective analytic using an observational approach which was conducted in three wards. The completeness of 95 nursing documentations was measured using an instrument. Nurses? workload was measured using a continuous observation technique with a sample of 46 nurses.The results showed that 71.6% was incomplete, and most of (52.2%) the nurses' workload was high. The most dominant factors affecting the completeness of the documentation are nurses? experiences in documentation training and workload. To conclude, there is a relationship between the period of employment, training and nurses?workload with the completeness of nursing documentation. Training on nursing documentation and reviewing on the number of nurses and staffing them according to workload in the room are necessary.
