scholarly journals Perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan berbasis kertas: Study literature

2020 ◽  
Vol 14 (1) ◽  
pp. 17-28
Author(s):  
Tomy Suganda ◽  
Rr Tutik Sri Hariyati
Keyword(s):  
Literature Review ◽  
Nursing Care ◽  
Strong Support ◽  
Cost Effective ◽  
Scientific Publication ◽  
Nursing Documentation ◽  
Health Records ◽  
Technological Developments ◽  
Paper Documentation

Paper‐based versus electronic‐based of health records in quality of nursing documentation: A literature review study.Background: Many technological developments in nursing services have emerged, one of them is electronic-based nursing documentation. The electronic nursing documentation has a good impact which increases the quality of service. But the readiness is still questionable.Purpose: Describing the quality comparison of electronic-based nursing documentation and paper-based nursing documentation.Method: This study uses a PRISMA literature review. Through the remote-lib.ui.ac.id database that is connected to various scientific publication pages such as, Scopus, Ebsco, PROQUEST Scholar-Articles with several key words such as electronic nursing documentation, nursing paper documentation, management information systems.Results: Electronic-based documentation has a higher level of quality documentation than paper-based documentation in terms of efficiency, effectiveness, patient focus and timeliness.Conclusion: Electronic-based documentation offers the optimization of nursing care, effective and efficient documentation, integrated nursing care and cost-effective through (paperless). Strong support from hospital institutions, organizations and government at the beginning of the nurse adaptation system and process is a challenge so that the application of electronic nursing documentation is realized properly.Keywords: Paper‐based; Electronic‐based; Health records; Quality; Nursing documentation.Pendahuluan: Pengembangan teknologi dalam pelayanan keperawatan banyak bermunculan, salah satunya dokumentasi keperawatan berbasis elektronik. Dokumentasi keperawatan elektronik memberikan dampak baik yang luarannya meningkatkan kualitas pelayanan. Namun kesiapan masih dipertanyakan.Tujuan: Menggambarkan perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan dokumentasi keperawatan berbasis kertas.Metode: Penelitian ini menggunakan tinjauan pustaka PRISMA. Melalui Database remote-lib.ui.ac.id yang terhubung dengan berbagai macam laman publikasi ilmiah seperti, Scopus, Ebsco, PROQUEST, Scholar-Artikel dengan beberapa kata kunci seperti dokumentasi keperawatan elektronik, dokumentasi keperawatan kertas, sistem informasi manajemen.Hasil: Dokumentasi berbasis elektronik memiliki tingkat kualitas dokumentasi lebih dibandingkan dokumentasi berbasis kertas secara efesiensi, efektifitas, fokus pada pasien maupun ketepatan waktu.Simpulan: Dokumentasi berbasis elektronik menawarkan keoptimalan melakukan asuhan keperawatan, dokumentasi efektif dan efesien, asuhan keperawatan terintegrasi serta cost-effective melalui (paperless). Dukungan kuat dari institusi rumah sakit, organisasi maupun pemerintah dalam permulaan sistem dan proses adaptasi perawat menjadi tantangan, agar penerapan dokumentasi keperawatan elektronik terealisasi dengan baik.

scholarly journals Metode Pendokumentasian Elektronik dalam Meningkatkan Kualitas Pelayanan Keperawatan

2018 ◽  
Vol 9 (3) ◽  
pp. 497
Author(s):  
Sulastri Sulastri ◽  
Niken Yuniar Sari
Keyword(s):  
Nursing Care ◽  
Information Exchange ◽  
Nursing Documentation ◽  
Documentation System ◽  
Care Services ◽  
Client Data ◽  
Technological Developments ◽  
Modern Era ◽  
Nursing Processes

Nursing documentation is one of the most important functions for nurses in providing nursing care. The nursing process in the modern era is now a demand from various aspects for nurses. The current development is that nurses must carry out nursing processes based on nursing care standards. The use of electronic nursing documentation can always evolve in line with technological developments, this can increase client life expectancy and reduce errors in intervening with clients. This IT-based documentation system will help in meeting documentation standards, can improve the quality of documentation, facilitate decision making and provide information that is easy to access, can minimize the potential for loss or damage to development records, improve information exchange and coordination between nurses or other health teams, documentation can be easily audited, help improve the accuracy of client data, can access the progress of client health development and reduce maintenance costs so that it can improve the quality of care services.

scholarly journals HUBUNGAN INTENSI DENGAN PERILAKU PERAWAT DALAM PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI INSTALASI GAWAT DARURAT

2018 ◽  
Vol 4 (1) ◽  
Author(s):  
Ardhiles Wahyu Kurniawan
Keyword(s):  
Health Care ◽  
Work Environment ◽  
Nursing Care ◽  
Care Process ◽  
Nursing Documentation ◽  
Exclusion Criteria ◽  
Cross Sectional ◽  
Good Intention ◽  
Care Health

Abstract : The complex IGD work environment will affect the quality of care, health care, including inaccurate or incomplete documentation. Incomplete nursing documentation indicates that the nursing care process is not working properly and continuously. Intentionin documenting can predict the appearance of person behavior including the behavior of nurses, especially in documenting nursing care. The purpose of this study was to analyze correlation intention with nurse behavior in documenting nursing care in Emergency Installation. The research design used correlational analysis with cross sectional approach. The sample in this research is part of nurse of executing at IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan and IGD RS Islam Malang. The sample of 45 nurses IGD and 341 documents were selected according to inclusion and exclusion criteria. The result of statistical analysis of gamma that there is a significant correlation between intention and nursing documentation behavior evidenced by value of p = 0,000, positive correlation direction and strong correlation value is proved by r = 0,739. Hospital and nurse IGD is expected to develop a good intention then formed good nursing documenting behavior as well.Keywords : Nurse IGD, Intention, Nursing Documentation. Abstrak: Lingkungan kerja IGD yang kompleks akan mempengaruhi kualitas perawatan, pelayanan kesehatan, termasuk dokumentasi yang dilakukan tidak tepat atau tidak lengkap. Dokumentasi keperawatan yang tidak lengkap menunjukkan proses asuhan keperawatan tidak berjalan dengan baik dan berkesinambungan. Intensi dalam pendokumentasian dapat memprediksi munculnya perilaku seseorang termasuk perilaku perawat khususnya dalam pendokumentasian asuhan keperawatan. Tujuan penelitian ini untuk menganalis hubungan intensi dengan perilaku perawat dalam pendokumentasian asuhan keperawatan di Instalasi Gawat Darurat. Desain penelitian menggunakan analysis correlationaldengan pendekatan cross sectional. Sampel dalam penelitian ini adalah sebagian perawat pelaksana di IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan Malang dan IGD RS Islam Malang. Sampel berjumlah 45 perawat IGD dan 341 dokumen dipilih sesuai dengan kriteria inklusi dan ekslusi. Hasil analisis statistik uji gammamenunjukkan terdapat hubungan signifikan antara intensi dengan perilaku pendokumentasian keperawatan dibuktikan dengan nilai p = 0,000, arah korelasi positif, dan nilai korelasi kuat dibuktikan dengan nilai r = 0,739. Rumah Sakit dan perawat IGD diharapkan mengembangkan intensi yang baik sehingga diharapkan terbentuk perilaku pendokumentasian keperawatan yang baik pula. Kata Kunci : Perawat IGD, Intensi, Dokumentasi Keperawatan.

scholarly journals Optimalisasi peran & fungsi manajemen kepala ruangan dalam supervisi dokumentasi asuhan keperawatan di rumah sakit x Jakarta

2021 ◽  
Vol 14 (4) ◽  
pp. 536-544
Author(s):  
Teresa Teresa ◽  
Tuti Afrianti ◽  
Tini Suminarti
Keyword(s):  
Quality Of Care ◽  
Nursing Care ◽  
Health Care Quality ◽  
Descriptive Analysis ◽  
Pilot Project ◽  
Poor Quality ◽  
Care Quality ◽  
Nursing Documentation ◽  
Head Nurse

The role of a head nurse in optimizing of management function in supervision of nursing care documentation at X hospital in JakartaBackground: Nursing documentation is important thing that  is indicator quality of care. Since the nursing documentation is still a poor quality, it requires a supervision by the head nurse.Purpose: The head of nursing is responsible for the direction, organization and strategic planning collaborate with nursing staffs in ensuring the quality of nursing care to achieve accurate, effective and efficient documentation and to complete supervision.Method: A pilot project using questionnaire and observation methods was conducted at difference times on two hospital units in Jakarta.Results: The descriptive analysis results showed that among 18 nurses, 4 nurses believed that nursing documentation is an important, effective and clear way to  ease their job. Hence, supervision is continuity needed to support the improvement of health care quality. The innovative projects will be applied in health care.Conclusion:  Nursing documentation must show continuity and quality of  care nursing under the control and supervision of the head nurse and EMR is used as the instrument for documentation.Keywords :  The role; Head nurse; Management; Supervision; Nursing care; DocumentationPendahuluan: Dokumentasi asuhan keperawatan adalah hal yang penting karena menjadi indikator kualitas perawatan. Penerapan dokumentasi asuhan keperawatan saat ini belum optimal sehingga membutuhkan arahan dan supervisi dari Kepala Ruang/Kepala Unit.Tujuan: Tercapainya supervisi dan keberhasilan pelaksanaan dokumentasi asuhan keperawatan yang komprehensif, berkesinambungan, efektif dan  efisien.Metode: Metode pilot project di salah satu Rumah Sakit di Jakarta dengan pengambilan data melalui  observasi dan kuestioner. Instrumen diujikan pada dua ruangan dalam  waktu yang berbeda.Hasil: Analisis deskripsi pada  sejumlah 18 perawat, 4 orang menyatakan bermanfaat, penting dan mudah dalam penerapannya. Supervisi dilakukan untuk memberikan support terhadap kelangsungan pendokumentasian asuhan keperawatan yang berkesinambungan. Proyek inovasi akan ditindaklanjuti dan diaplikasikan dalam program kerja bidang pelayanan keperawatan.Simpulan: Asuhan keperawatan yang berkualitas memerlukan adanya supervisi. Sarannya penggunaan Instrumen Supervise Dokumentasi Asuhan Keperawatan akan disesuaikan dengan penggunaan pencatatan asuhan keperawatan Elektronic Medical Record/EMR

Use of quality-adjusted life years for the estimation of effectiveness of health care: A systematic literature review

2006 ◽  
Vol 22 (2) ◽  
pp. 235-241 ◽  
Author(s):  
Pirjo Räsänen ◽  
Eija Roine ◽  
Harri Sintonen ◽  
Virpi Semberg-Konttinen ◽  
Olli-Pekka Ryynänen ◽  
...  
Keyword(s):  
Health Care ◽  
Literature Review ◽  
Systematic Literature Review ◽  
Full Text ◽  
Cost Effective ◽  
Quality Adjusted Life Years ◽  
Hrqol Instrument ◽  
Life Years ◽  
Quality Adjusted Life

Objectives: The objectives of this study were to identify, in a systematic literature review, published studies having used quality-adjusted life years (QALYs) based on actual measurements of patients' health-related quality of life (HRQoL) and to determine which HRQoL instruments have been used to calculate QALYs. Furthermore, the aims were to characterize studies with regard to medical specialty, intervention studied, results obtained, quality, country of origin, QALY gain observed, and interpretation of results regarding cost-effectiveness.Methods: Systematic searches of the literature were made using the MEDLINE, Embase, CINAHL, SCI, and Cochrane Library electronic databases. Initial screening of identified articles was based on abstracts read independently by two of the authors; full-text articles were again evaluated by two authors, who made the final decision on which articles should be included.Results: The search identified 3,882 articles; 624 were obtained for closer review. Of the reviewed full-text articles, seventy reported QALYs based on actual before–after measurements using a valid HRQoL instrument. The most frequently used instrument was EuroQol HRQoL instrument (EQ-5D, 47.5 percent). Other instruments used were Health Utilities Index (HUI, 8.8 percent), the Rosser–Kind Index (6.3 percent), Quality of Well-Being (QWB, 6.3 percent), Short Form-6D (SF-6D, 5.0 percent), and 15D (2.5 percent). The rest (23.8 percent) used a direct valuation method: Time Trade-Off (10.0 percent), Standard Gamble (5.0 percent), visual analogue scale (5.0 percent), or rating scale (3.8 percent). The most frequently studied medical specialties were orthopedics (15.5 percent), pulmonary diseases (12.7 percent), and cardiology (9.9 percent). Ninety percent of the studies came from four countries: United Kingdom, United States, Canada, the Netherlands. Approximately half of the papers were methodologically high quality randomized trials. Forty-nine percent of the studied interventions were viewed by the authors of the original studies as being cost-effective; only 13 percent of interventions were deemed not to be cost-effective.Conclusions: Although QALYs gained are considered an important measure of effectiveness of health care, the number of studies in which QALYs are based on actual measurements of patients' HRQoL is still fairly limited.

scholarly journals Kepatuhan Perawat dalam Melakukan Dokumentasi Asuhan Keperawatan

2020 ◽  
Vol 3 (1) ◽  
pp. 17-23
Author(s):  
Ni Kadek Erna ◽  
Ni Luh Putu Thrisna Dewi
Keyword(s):  
Nursing Education ◽  
Nursing Care ◽  
Self Efficacy ◽  
P Value ◽  
Nursing Documentation ◽  
Cross Sectional ◽  
Nursing Services ◽  
Cross Sectional Design ◽  
Spearman Test

Introduction: Nurses' lack of understanding and non-compliance in nursing documentation resulted in low quality of documentation and nursing services. One of factors which affects nursing documentation is self-efficacy. The purpose of this study was to know the correlation of self-efficacy and the compliance of nurses in the nursing documentation. Methods: This research used cross-sectional design with the descriptive documentation approach. The sample of the study was 23 nurses in a hospital recruiting with a nonprobability technique type i.e. total sampling. The inclusion criteria in this study were nurses who were willing to be respondents and had at least a diploma in nursing education. The instrument used was a self-efficacy questionnaire and the nursing care documentation compliance observation sheet. Data analysis used Rank Spearman test with the meaning level 0.05. Results: Most of nurses had high self-efficacy (69.9%) and majority nurse obey in nursing care documentation (73.9%). The statistic test showed p value = 0.000 < (0.05) with r = 0.898. Conclusion: This result confirmed that there is a relation between self-efficacy and the compliance of nurses in nursing documentation at hospital.

scholarly journals Research in the Nursing Care Group - UniSabana and Aquichan: Track Record and Challenges

Aquichan ◽  
2021 ◽  
Vol 21 (4) ◽  
pp. 1-4
Author(s):  
Gloria Carvajal Carrascal
Keyword(s):  
Nursing Care ◽  
Research Priorities ◽  
Well Being ◽  
Scientific Publication ◽  
Care Group ◽  
Nursing Interventions ◽  
Nursing Knowledge ◽  
Care Experience ◽  
Track Record

The Nursing Care Group - UniSabana seeks to produce scientific knowledge that, aligned with national and global care and research priorities, favors the understanding of the conditions that adversely affect the population’s health and the development of simple and complex nursing interventions. In the framework of interdisciplinary, international, and intersectoral endeavors, the group aims to transfer this knowledge to base professional practice in multiple settings and transform people’s health care experience for their well-being and quality of life. Aquichan Journal, as a scientific publication, guarantees the quality of its editorial processes to contribute to the visibility of nursing knowledge in the hope that it will be replicated to promote the discipline’s theoretical and research evolution.

scholarly journals Analysis of The Study of The Supervision of Nursing Room In The Implementation of Nursing Supervision

2020 ◽  
Vol 2 (3) ◽  
pp. 123
Author(s):  
Etik Kustiati ◽  
Vivi Yosafianti Pohan ◽  
Tri Hartiti
Keyword(s):  
Quality Of Service ◽  
Human Resources ◽  
Small Group ◽  
Nursing Care ◽  
Service Needs ◽  
Nursing Management ◽  
Nursing Documentation ◽  
Direct Supervision ◽  
Management Functions

Preparaing rooms for covid 19 patients must be supported by the availability of superior human resources and good nursing management functions. Nursing care given to Covid 19 patients must be complete and well documented. The quality of service needs to be monitored on an ongoing basis by optimizing the supervisory function of the head of the room and the orphans by means of nursing supervision. The purpose of this analysis is to determine the usefulness of the nursing room supervision function in this case by implementing nursing supervision. The use of the action method in this analysis aims to develop new skills or new approaches and be applied directly and studied the results. The assessment using eight nursing management functions carried out in Sulaiman 4 room Roemani Muhammadiyah Semarang Hospital found that the most priority problems were not optimal in the implementation of the supervisory activities of the head of the room and head of the team. The supervision activities in the Sulaiman 4 room have actually been carried out but have not been scheduled and well documented. Actions taken by refreshing the nursing supervision through Small Group Discus activities, preparation of supervision schedules and making supervision formats. Evaluation of the actions taken, SGD was attended by 19 participants consisting of 15 nurses Sulaiman 4 and four other inpatient heads, the supervision schedule was made according to the agreement of the Head of the Room and the Head of the Team. The direct supervision format was used in Sulaiman 4 room according to the predetermined schedule, namely on December 11, 2020. The results achieved from the supervision obtained a significant increase in the number of completeness of nursing documentation from 48.24% to 82.98%.

scholarly journals Analysis of Nursing Documentation Implementation In Outpatient Room

2020 ◽  
Vol 2 (2) ◽  
pp. 25
Author(s):  
Muhamad Nurudin ◽  
Vivi Yosafianti Pohan ◽  
Tri Hartiti
Keyword(s):  
Medical Record ◽  
Nursing Care ◽  
Initial Assessment ◽  
Nursing Management ◽  
Management Skills ◽  
Nursing Documentation ◽  
Nursing Support ◽  
Service Unit ◽  
Medical Record Documentation

The quality of nursing care is a key element of service quality in hospitals. To realize good quality nursing service and quality in the Outpatient Institution, qualified human resources are also needed and good nursing management skills are needed from a manager or head of the service unit. For the implementation of nursing care documentation in outpatient installations to be carried out optimally, it is necessary to carry out management activities in the form of supervision by carrying out nursing support activities in stages. The purpose of this analysis is to determine the implementation of outpatient nursing medical record documentation. The use of action methods in this analysis aims to develop new skills or new approaches and be applied directly and reviewed the results. From the results of the assessment found several nursing management problems and the priority is the completeness of outpatient nursing medical record documentation which is still low. The action taken is by providing refresher activities or material refreshing on nursing documentation, initial assessment of outpatients, simulations of filling out initial outpatient assessment documentation, making and disseminating supervision forms and techniques for tiered supervision using the supervision form. The activity was attended by 23 participants consisting of the head of the room, the team leader and the nurse executing from the polyclinic or outpatient installation. Evaluation after carrying out activities on the completeness of outpatient nursing medical record documentation was 70%  (14 of 20 samples).

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