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All Journal Journal of Telenursing (JOTING)
Khairul Nasri
Rumah Sakit Umum Pusat Fatmawati
Health Professions Nursing

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Optimalisasi Penegakan Diagnosis Keperawatan Sesuai Standar Asuhan Keperawatan di Rumah Sakit X Mu'minah Mu'minah; Tuti Afriani; Krisna Yetti; Dudi Mashudi; Khairul Nasri
Journal of Telenursing (JOTING) Vol 5 No 2 (2023): Journal of Telenursing (JOTING)
Publisher : Institut Penelitian Matematika, Komputer, Keperawatan, Pendidikan dan Ekonomi (IPM2KPE)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31539/joting.v5i2.5875

Abstract

This study aims to analyze the enforcement of nursing diagnoses according to the Nursing Care Standards of X Hospital Jakarta. The research method uses a case study approach with interviews, document review and observation, and performs problem analysis using fishbone analysis. The results showed that the enforcement of nursing diagnoses in accordance with the Standards of Nursing Care was not optimal, so that it had an impact on the quality of care and its documentation. Nursing diagnoses that are in accordance with Nursing Care Standards are 48.6%. Lack of supervision from managers, assessments using personal assumptions and the standard of writing diagnoses in the local Hospital Information System (SIRS) has not been facilitated. Through strengthening the directing function with SAK media innovation, there was an increase in writing nursing diagnoses according to SAK to 62.3%. In conclusion, optimizing the enforcement of nursing diagnoses in accordance with Nursing Care Standards can be implemented with SAK media innovations (Softfiles on the Google Form Platform and flipcharts) which are given to implementing nurses at X Hospital. Keywords: Diagnosis, Nursing Documentation, Quality, Nursing Care Standards
Optimalisasi Supervisi Berjenjang Kelengkapan Dokumentasi Keperawatan Reidha Fitri Nurbaeti; Tuti Afriani; Hanny Handiyani; Khairul Nasri; Sudaryati Sudaryati
Journal of Telenursing (JOTING) Vol 5 No 2 (2023): Journal of Telenursing (JOTING)
Publisher : Institut Penelitian Matematika, Komputer, Keperawatan, Pendidikan dan Ekonomi (IPM2KPE)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31539/joting.v5i2.7602

Abstract

This research aims to identify the optimization of the implementation of tiered supervision for the completeness of nursing documentation in inpatient rooms. The method used is a case study approach with interviews, document review, observation, and problem analysis using fishbone analysis. The research results show that all nursing managers can optimize the implementation of tiered supervision for the completeness of nursing documentation. Nursing managers can carry out routine maintenance of staff under them regarding the suitability of the diagnoses raised with subjective and objective data collected from the results of assessments carried out by nurses, proven by trials of implementing tiered supervision in three inpatient rooms with observational evaluations, and data obtained that there is an increase in the percentage of conformity of diagnoses. First nursing with subjective and objective data from 43.4% to 82.6%, and second diagnosis from 52.1% to 95.65%. The room is in the refreezing change stage where, after implementation or trial, the Nursing Services Department and the head of the room, along with the PPJA and PA, are trying to maintain its continuity and become an organizational culture in the hospital. The conclusion of the activities carried out during the socialization and mentoring process has provided changes in behavior and mindset for nurses in implementing tiered supervision for completeness of nursing documentation on a routine and scheduled schedule. Keywords: Nursing Documentation, Nurse Manager, Tiered Supervision
Co-Authors Dudi Mashudi Hanny Handiyani Krisna Yetti Mu'minah Mu'minah Reidha Fitri Nurbaeti Sudaryati Sudaryati Tuti Afriani