ANALISIS HUBUNGAN PELAKSANAAN SUPERVISI KLINIK MODEL 4S DENGAN INDIKATOR PENDOKUMENTASIAN PENCATATAN TERINTEGRASI DI RSU UNIVERSITAS RIAU

Abstract

ABSTRAK

 Dokumentasi merupakan sarana komunikasi afektif antar profesi kesehatan. Rendahnya kualitas pendokumentasian catatan terintegrasi di Indonesia  meliputi tidak lengkapnya pengisian form CPPT dimana didapatkan tidak terisinya identitas pasien, tanggal dan jam visit, serta nama dan tanda-tangan PA secara lengkap, serta kurangnya kedisiplinan pengisian rekam medis oleh PPA. Karakteristik perawat merupakan faktor individu yang mempengaruhi kinerja pendokumentasian. Form tindakan perawat merupakan media komunikasi  perawat dalam melakukan asuhan keperawatan berupa tanggal, waktu dan uraian kegiatan yang dilakukan. Tujuan tesis adalah menganalisis hubungan pelaksanaan supervisi klinik model 4S dengan indikator pendokumentasian terintegrasi di RSU Universitas Riau. Penelitian ini merupakan penelitian kuantitatif dengan pendekatan cross sectional. Sampel penelitian berjumlah 33 orang dengan teknik pengambilan sampel total sampling. Penelitian menggunakan kuesioner dan lembar observasi yang sudah teruji validitas dan reliabilitasnya. Melalui statistik terdapat hubungan karakter (p value=0,000), kooperatif (p value =0,008), kompeten (p value=0,000) dan komunikatif (p value=0,000) terhadap pelaksanaan supervise klinik model 4S. Terdapat hubungan pelaksanaan persiapan (p value= 0,000), pelaksanaan (p value = 0,001) dan evaluasi (p value = 0,000) terhadap supervisi terhadap CPPT di RSU Universitas Riau. Peneliti merekomendasikan peran supervisi untuk peningkatan kompetensi dan kepatuhan perawat dalam pelaksanaan pendokumetasian keperawatan RS.

ABSTRACT

Documentation is a means of affective communication between health professions. The low quality of integrated record documentation in Indonesia includes incomplete filling of the CPPT form where it is found that patient identity, date and time of visit are not filled, as well as PA's name and signature in full, as well as lack of discipline in filling out medical records by PPA. The characteristics of nurses are individual factors that affect the performance of documentation. The nurse's action form is a communication medium for nurses in carrying out nursing care in the form of date, time and description of the activities carried out. The purpose of the thesis is to analyze the relationship between the implementation of clinical supervision of the 4S model with integrated documentation indicators at the Riau University General Hospital. This research is a quantitative research with a cross sectional approach. The research sample amounted to 33 people with a total sampling technique of sampling. The research uses questionnaires and observation sheets that have been tested for validity and reliability. Through statistics, there is a character relationship (p value = 0.000), cooperative (p value = 0.008), competent (p value = 0.000) and communicative (p value = 0.000) on the implementation of 4S model clinical supervision, there is a relationship between the implementation of preparation (p value = 0.000), implementation (p value = 0.001) and evaluation (p value = 0.000) on the supervision of CPPT at RSU Riau University. The researcher recommends the role of supervision to increase the competence and compliance of nurses in the implementation of hospital nursing documentation.