Evaluasi Kualitas Dokumentasi Diagnosis, Intervensi, dan Outcomes Keperawatan di RS X Jember

Abstract

Dokumentasi asuhan keperawatan merupakan indikator penting dalam menjamin kualitas pelayanan yang aman, efektif, dan berkesinambungan. Penelitian ini bertujuan untuk mengevaluasi kualitas dokumentasi diagnosis, intervensi, dan outcomes keperawatan di RS X Kota Jember menggunakan instrumen Quality of Documentation Nursing Diagnosis, Intervention, and Outcomes (Q-DIO). Desain penelitian yang digunakan adalah kuantitatif deskriptif dengan sampel sebanyak 90 dokumen rekam medis pasien rawat inap yang dipilih secara purposive sampling pada periode September hingga November 2023. Hasil menunjukkan bahwa kualitas dokumentasi diagnosis keperawatan sebagai proses sebesar 51,1%, sebagai produk sebesar 60%, intervensi keperawatan sebesar 68,9%, dan outcomes keperawatan sebesar 86,7%. Meskipun mayoritas aspek menunjukkan kualitas tinggi, ditemukan beberapa kelemahan seperti ketidaksesuaian antara data pengkajian dan diagnosis, serta kurangnya pendokumentasian aspek sosial dan psikologis pasien. Penelitian ini merekomendasikan perlunya peningkatan mutu dokumentasi melalui pelatihan rutin, supervisi klinis, serta penguatan sistem informasi keperawatan berbasis elektronik guna mendukung praktik keperawatan yang akuntabel dan terstandar.

Nursing care documentation is an important indicator in ensuring the quality of safe, effective, and sustainable services. This study aims to evaluate the quality of documentation of nursing diagnoses, interventions, and outcomes at X Hospital in Jember City using the Quality of Documentation Nursing Diagnosis, Intervention, and Outcomes (Q-DIO) instrument. The research design used was descriptive quantitative with a sample of 90 inpatient medical record documents selected by purposive sampling in the period September to November 2023. The results showed that the quality of nursing diagnosis documentation as a process was 51.1%, as a product was 60%, nursing interventions were 68.9%, and nursing outcomes were 86.7%. Although the majority of aspects showed high quality, there were some weaknesses such as discrepancies between assessment and diagnosis data, and lack of documentation of social and psychological aspects of patients. This study recommends the need to improve the quality of documentation through regular training, clinical supervision, and strengthening electronic-based nursing information systems to support accountable and standardized nursing practice.