PENERAPAN DOKUMENTASI KEPERAWATAN BERDASARKAN STANDAR SNARS DI RSI SAKINAH MOJOKERTO

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.