Implementation of Documentation of Nursing Care in Wates Hospital

The documentation of nursing care is the important part nurse duty, the best documentation of nursing care process that sees best and have a certain quality should be acurate, complete, and standard. Curently documenting of nursing care in Wates Hospital is practically not yet done according to Standard Operational Procedure. This study aims to know the description of the nursing care of documentation in Inpatient Room of Wates Hospital. This research is descriptive quantitatif which take the sample from inpatient documentation of nursing care in March 2017. The population was about 1106 documents of medical records which the sample obout 111 documents. The technique to take the sample was using cluster random. The research was held on June 2017. The data collection used medical record of patient. The univariat of data analysis used frequency distribution. This research showd that the completeness os documenting of nursing care in assessment aspect (77,5%), diagnosis (93,7%), planning (73,9%), action (45,9%), evaluation (76,6%), nursing care note (45%). The completeness of documentation of nursing care in Inpatient Room of Wates Hospital Kulon Progo is claimed complete (27,9%).


INTRODUCTION
Nurse profession is currently a profession that has a very high legal risk. in carrying out nursing care the need for documentation so that it can become documentation of evidence in court, quality (quality of service) as communication between health workers, cost reference, educational references, object of research, can assess the extent of the role of nurses in providing nursing care, errors in his job can drag the nurse to court.Therefore all activities carried out on patients must be well documented and clear.Documentation is written communication so nurses are required to document correctly.The standard of nursing care is a measuring tool to maintain and improve the quality of nursing care.The standard serves as a measuring tool for knowing, monitoring, and concluding whether nursing care services held in hospitals have followed and fulfi lled the requirements set by these standards (4).Containing the quality of the process of nursing care documentation with alternative answers is complete and incomplete, the number of questions is 24 items.Each answer option is given code 1 = (if the documentation is complete) and 0 = (if the documentation is incomplete).Based on Table 2, the distribution of assessments on aspects of assessment shows that recording the data reviewed according to guidelines is the most incomplete action done, namely as many as 23 documents (20.7%)Based on Table 8 shows that the actions taken by nurses referring to the treatment plan are the most incomplete actions, namely as many as 38 documents (34.2%).

RESULTS AND DISCUSSION
Effective documentation allows nurses to communicate to other personnel (1).Documentation is a means of communication between health workers in the framework of recovering the health of patients, without proper and clear documentation the nursing service activities in the form of nursing care that have been carried out by professional nurses cannot be accounted for.Documentation can be used as evidence must be identified in full, clear, objective, and signed by the nurse, the date and need for avoidance of writing that lead to incorrect interpretation (1-3).PERMENKES No. 148 of 2010 and the Nursing Act 38 of 2014 states that nurses are authorized to perform nursing care and are obliged to systematically record nursing care and standards.Nursing care standards are enforced through the Decree of the Director General of YanMed No. YM.00.03.26.7637 1993

Table 1 . Completeness of nursing assessment documentation at Wates Hospital
Documentation description of nursing care is reviewed from each aspect of the research in the table and presented

Table 3 . Completeness of Nursing Diagnosis Documentation at Wates Hospital
B a s e d o n Ta b l e 3 , t h e c o m p l e t e documentation on aspects of nursing diagnoses is in full category there are 104 documents (93.7%) and incomplete there are 7 documents (6.3%).

Table 4
shows that the act of formulating an actual or potential nursing diagnosis is the most incomplete action performed by the nurse, which is 5 documents (4.5%).

Table 12 . Frequency Distribution of Complete Documentation of Nursing Records in Wates Hospital in March 2017 (n=111)
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