Abstract:
Documentation was generally less favored by nurses because it is considered too complicated, diverse, and time-consuming, but nursing documentation that was not carried out properly, completely and accurately can reduce the quality of nursing services because it cannot identify the extent to which the level of success of nursing care that has been provided. This study aimed to describe the performance of nurses in documenting nursing care at Prof.Dr.Soekandar Mojosari Hospital. The design of this study used a descriptive design. The population in this study were all nurses in RSUD Prof. Dr. Soekandar Mojosari, Mojokerto Regency, with a total of 219 nurses. The sampling technique of this research was proportionate stratified random sampling. The sample in this study amounted to 69 people. The research instrument used a checklist. Data analysis used frequency distribution table and percentage. The results suggested that almost all respondents had good performance in the documentation of nursing care, as many as 63 people (91.3%), and nurses who had adequate performance were 6 people (8.7%). Analysis of the description of the performance of nurses in the documentation of nursing care at Prof. Hospital. Dr. Soekandar Mojosari Mojokerto was almost entirely good, and the best indicator of nurse performance was in terms of conducting assessments and implementation. This is because the assessment is a determinant of interventions and actions taken to patients, and implementation is also an important part of treatment actions for patients. All nursing care is carried out according to hospital rules, although there are some things that cannot always be done, this also adjusts to the conditions that exist in the hospital.
