Abstract:
Most of the nurses underestimate the incomplete filling of nursing
documentation, for example filling in nursing care or patient progress notes
(CPPT). nursing standards, namely conducting independent assessments and
recorded in the patient's progress note (CPPT) every 3 times in order to find out
the patient's development condition. The purpose of this study was to describe
nursing documentation based on standard snars at Rsi Sakinah Mojokerto. This
research design uses a descriptive design. The number of research samples 25
medical records with random sampling technique. This study uses a reliability test
that is carried out jointly on all questions for more than one variable, the
reliability test is a variable that is said to be good if it has a Cronbachs Alpha
value> 0.60.The results of the most research on the application of documentation
nursing care standards at Rsi Sakinah Mojokerto show that most of the
documentation standards in Rsi Sakinah Mojokerto are 17 respondents (68%) with
complete aspects.Whereas for partially fulfilled as many as 8 respondents (32%),
assessment indicators 86%, diagnosis 82%, intervension 88%, implementation
84%, and evaluation 80%, So said to be good this is shown from the complete
results because the hospital has standards patient-focused services to improve
quality and patient safety with a risk management approach in the hospital.
