Abstract:
Nursing documentation is crucial as evidence and accountability for nursing actions. Several obstacles related to the documentation of nursing care, namely the lack of understanding of the basics of nursing documentation. To get good results, a nurse really needs supervision, direction and assistance through supervision activities. This study aimed to determine the relationship between the supervision of the head of the room with the performance of nurses in documenting nursing care at R.A Basoeni Gedeg Hospital. This research design used correlation analytic with cross sectional approach. The population in this study were all 121 associate nurses and 15 medical record officers at RSUD R.A Basoeni Mojokerto. The sampling technique of this research was purposive sampling. The sample in this study amounted to 30 people. The research instrument used a checklist sheet. Data analysis used Fisher's Exact Test. The results showed that most of the respondents rated the supervision of the head of the room as good, as many as 22 people (73.3%) and almost all of them had good performance in documenting nursing care, as many as 26 people (86.7%). Fisher's Exact Test results with p value = 0.003 < = 0.05 so that there was relationship between room head supervision and the performance of nurses in documenting nursing care at R.A Basoeni Gedeg Hospital, Mojokerto. This shows that the better the supervision of the head of the room will be followed by the good performance of nurses in documenting nursing care.
