ABSTRAKKelengkapan pengisian dokumen pengkajian keperawatan sangat rendah. Saat ini belum diketahui sejauh mana persepsi perawat terhadap pelaksanaan dokumentasi pengkajian di 6 ruang rawat inap RSUD Pasar Rebo Jakarta.Penelitian ini menggunakan metode kualitatif dengan rancangan studi kasus yang menekankan pada persepsi perawat mengenai pelaksanaan dokumentasi pengkajian keperawatan. Pengumpulan data mengenai faktor masukan, proses, dan keluaran dari pelaksanaan dokumentasi pengkajian keperawatan dilakukan melalui wawancara terhadap 1 orang ketua komite keperawatan, 6 perawat pelaksana, dan 6 kepala ruangan, pengamatan terhadap proses pengkajian, serta Pengamatan terhadap dukumen pengkajian di 6 ruang rawat inap.Hasil penel i tian menunjukkan kelengkapan dokumen pengkajian keperawatan masih rendah. Persepsi perawat terhadap tenaga perawat yang melakukan pendokumentasian pengkajian, memerlukan pendidikan D.III Keperawatara. Sarana pendokumentasian berupa formulir yang disederhaanakan tidak dapat memunculkan kebutuhan .data pasien secara menyeluruh, sedangkan buku pedoman penulisan yang ada jarang dibaca. Metode pendokumentasian pengkajian sama untuk seluruh ruangan, namun kurang jelas dalam,car.a pengumpulan maupun penulisan kebutuhan data pasien secara menyeluruh. Manajemen keperawatan dinilai masih kurang dalam menjalankan proses manajemen baik dalam perencanaan, pengorganisasian, pengarahan, maupun pengawasan, terhadap pelaksanaan proses keperawatan.Kesimpulannya pelaksanaan dokumentasi pengkajian keperawatan menurut persepsi perawat dipengaruhi oleh kekurangan dalam faktor tenaga perawat, sarana, metode, dan manajemen keperawatan.Untuk itu saran dari penelitian ini adalah penambahan dasar pengetahuan bagi perawat SPK, perbaikan sarana dan metode pendokumentasian pengkajian keperawatan, dan penataan kembali manajemen keperawatan.

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ABSTRACT

Nurse's Perception On Nursing Assessment Documentation Of In-Patient Care Department at Pasar Rebo HospitalThe complete of nursing assessment documentation is found very poor. There is no trace of nurse's perception on nursing assessment documentation in 6 units of in-patient department at Pasar Rebo Hospital.

This was a study case design of qualitative method, which concerned on nurse's perception on nursing assessment documentation. Data about input, process, and output factors of the documentation were gathered by interviewing the chief of nursing committee, 6 technical nurses, and 6 chief of nursing units; observing the process of nursing assessment; and observing the nursing assessment documents of 6 in-patient units.

This study found that the completeness of nursing assessment documentation was poor. The nurse's perception on nursing personnel who did the documentation have to be a D.1I1 of Nursing graduates. The fac_i l i ties of documentation such as a simplified form cannot perform proper patient's data collection thoroughly. In the mean Lime, the guidance of documentation has been rarely read. The same method of documentation has been established, but it contains not clear enough to fulfill patient's data collection in collecting itself, as well as completing. The nursing management has not properly run, as seen in the lack of planning, organizing, directing, or controlling of nursing care process.

In conclusion, nurse's perception on nursing assessment documentation has been influenced by the lack of nursing personnel, facilities, method, and nursing management.

Therefore, this study recommends an improvement of basic knowledge'for nursing personnel SPK graduates, facilities and method of nursing assessment documentation, and a reformation of nursing management.