Sistem Dokumentasi Digital untuk Peningkatan Mutu Dokumentasi Keperawatan Medikal Bedah
DOI:
https://doi.org/10.37287/jppp.v7i6.994Keywords:
dokumentasi keperawatan, efisiensi pencatatan, mutu layanan, SI-Askep, sistem digitalAbstract
Dokumentasi keperawatan merupakan komponen penting dalam menjamin mutu pelayanan dan keselamatan pasien. Namun, praktik dokumentasi manual sering mengalami kendala seperti ketidaklengkapan data, keterlambatan pencatatan, serta risiko kehilangan informasi. Penelitian ini bertujuan mengembangkan dan mengevaluasi sistem dokumentasi digital SI-Askep untuk meningkatkan kelengkapan dan efisiensi dokumentasi keperawatan di ruang medik bedah. Desain penelitian menggunakan pendekatan Research and Development (R&D) yang mencakup analisis kebutuhan, pengembangan prototipe, validasi ahli, dan uji coba terbatas pada sepuluh perawat. Data kelengkapan dokumentasi, efisiensi waktu pencatatan, dan kebergunaan sistem dikumpulkan melalui checklist, observasi, serta kuesioner System Usability Scale (SUS). Uji statistik Wilcoxon Signed Rank Test digunakan untuk menganalisis perbedaan sebelum dan sesudah penggunaan SI-Askep. Hasil penelitian menunjukkan peningkatan signifikan pada kelengkapan dokumentasi dari 58% menjadi 92% (p < 0.05), serta penurunan waktu pencatatan dari 16–20 menit menjadi 7–10 menit. Tingkat kebergunaan juga sangat baik dengan skor SUS sebesar 82. Temuan ini menunjukkan bahwa SI-Askep efektif dalam meningkatkan mutu dokumentasi keperawatan, mempercepat alur kerja, dan memberikan pengalaman penggunaan yang positif bagi perawat. Dengan demikian, SI-Askep berpotensi diadopsi secara lebih luas sebagai inovasi digital untuk meningkatkan praktik dokumentasi keperawatan di fasilitas kesehatan.
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