Hubungan Antara Pengetahuan Perawat Tentang Rekam Medis dan Dokumentasi Keperawatan Dengan Kelengkapan Pencatatan Dokumentasi Keperawatan di Klinik MTA Surakarta 2019

Abstract

Klinik Pratama MTA Surakarta has service support that is used to present information in the form of patient nursing records in medical records. The nurse has an obligation to make documentation of the nursing care actions that she does. The preliminary preliminary survey found that there were 6 respondents who were not well informed about medical records, 2 respondents were not well informed about nursing documentation, and 5 documents were incomplete. The purpose of this study was to determine the relationship between nurses' knowledge about medical records and nursing documentation with the complete recording of nursing documentation. This research was conducted using descriptive surveys of quantitative methods with a cross sectional study approach. The object of the research is the completeness of the nursing documentation records in the medical record. The research subjects were taken by total sampling, namely all nurses as many as 36 respondents and 36 documents. The research instrument used a questionnaire and observation guidelines. Quantitative data analysis using the chi-square relationship test. The results of this study from 36 respondents based on the Chi-Square test were significant between nurses' knowledge variables about medical records with completeness of nursing documentation by 0.003 (p <0.05) then Ho was rejected and there was a relationship and from 36 respondents based on Chi-test results Square significance of the variable knowledge of nurses about nursing documentation with complete nursing documentation is 0.015 (p <0.05), so Ho is rejected and also stated there is a relationship. Conclusion there is a relationship between nurses' knowledge of medical records and nursing documentation with complete recording of nursing documentation At the 2019 Surakarta MTA Clinic. Suggestions should provide education, training and seminars related to medical records and nursing documentation records and look for the completeness of the factors that influence the completeness of nursing documentation.

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