"Pendokumentasian asuhan keperawatan dalam pelaksanaannya merupakan hal yang rumit. Beberapa upaya telah dilakukan dalam mengatasi permasalahan pendokumentasian. Namun belum ada penelitian yang menggali pendokumentasian dikaitkan dengan integritas perawat. Tujuan penelitian mengeksplorasi pengalaman perawat dalam pendokumentasian asuhan keperawatan kaitannya dengan integritas. Penelitian kualitatif dengan pendekatan fenomenologi deskriptif melibatkan 10 perawat di salah satu RS pemerintah. Metode dilakukan dengan wawancara mendalam. Data dianalisis menggunakan analisis Colaizzi.
Hasil penelitian mendapatkan tujuh tema meliputi 1) Menuliskan pendokumentasian asuhan keperawatan sesuai proses asuhan keperawatan, pendokumentasian terintegrasi oleh perawat yang berperan sesuai SPO, 2) Mendokumentasikan asuhan keperawatan belum sesuai SPO dan pedoman pengorganisasian pelayanan keperawatan yang dipengaruhi oleh faktor dari SDM perawat, metode penugasan, dan, material RS, 3) Merasakan beragam perasaan senang jika berhasil mendokumentasikan dan beragam perasaan bersalah jika belum mendokumentasikan 4) Mendapatkan manfaat pendokumentasian asuhan keperawatan, 5) Mengalami hambatan dan upaya mengatasi hambatan dalam pendokumentasian asuhan keperawataan, 6) Memahami integritas dalam pendokumentasian sebagai kemampuan kognitif, memiliki prinsip nilai, kejujuran, bertanggung jawab, dapat diperhitungkan, sesuai SPO, berkomitmen, kompeten, konsisten, sesuai identitas diri dan mengimplementasikan asuhan yang aman 7) Mengharapkan perawat semakin pintar, terampil dengan pendidikan berkelanjutan, adanya sistem JCI, akreditasi menertibkan pendokumentasian dan pendokumentasian yang lebih spesifik dan terkomputerisasi Secara umum belum semuanya partisipan melakukan pendokumentasian asuhan keperawatan secara berintegritas. Perawat perlu meningkatkan integritas dalam pendokumentasaian asuhan keperawatan. Perawat dapat melakukan pendokumentasian secara berintegritas harus didikukung oleh manajemen rumah sakit dan tim keperawatan.
Documentation of nursing care in its implementation is a complicated matter. Several efforts have been made in overcoming documentation problems. However, no research has been conducted to explore the documentation associated with nurse integrity. The purpose of the study explores the nurse`s experience in documenting nursing care in relation to integrity. Qualitative research with descriptive phenomenology approach involved 10 nurses in one of the government hospitals. The method is done by in-depth interviews. Data were analyzed using Colaizzi`s analysis.The results of the study obtained seven themes including 1) Writing down the documentation of nursing care according to the nursing care process, integrated documentation by nurses who acted according to SPO, 2) Documenting nursing care not in accordance with SPO and guideline for organizing nursing services that were influenced by factors from nurses human resource, assignment methods, and, hospital material, 3) Feeling a variety of happy feelings when successfully documenting and varying feelings of guilt if it has not documented 4) Getting the benefits of nursing care documentation, 5) Experiencing obstacles and efforts to overcome obstacles in nursing care documentation, 6) Understanding integrity in documentation as an ability cognitive, has the principle of value, honesty, is responsible, can be calculated, according to SPO, is committed, competent, consistent, in accordance with self-identity and implements safe care 7) Expects nurses to be smarter, skilled with educators continuous, the existence of a JCI system, accreditation in order to document and more specific and computerized documentation In general, not all participants have documented nursing care with integrity. Nurses need to improve integrity in documenting nursing care. Nurses can document with integrity must be supported by hospital management and the nursing team."
