Utilization of the SIMPACA Application to improve the quality of nursing care documentation for nurses

Jum Natosba; Jaji Jaji; Nurna Ningsih; Herliawati Herliawati; Fuji Rahmawati; Karolin Adhisty

doi:10.26905/abdimas.v7i2.6837

Utilization of the SIMPACA Application to improve the quality of nursing care documentation for nurses

Jum Natosba, Jaji Jaji, Nurna Ningsih, Herliawati Herliawati, Fuji Rahmawati, Karolin Adhisty

Abstract

The phenomenon of nurses in hospitals being preoccupied with recording documentation activities manually compared to providing independent nursing care to patients. One of the reasons for improving the behavior of nurses in documenting nursing care is increasing the ability of nurses to do documentation using application assistance to facilitate the work of nurses. This community service activity aims to improve the ability of nurses to document effectively and efficiently. The activity was carried out for two days through a zoom meeting. Previously, at the beginning of the activity, a nurse's ability pre-test was conducted and at the end of the session, another measurement was made for the nurse's ability. Community service activities were carried out with 45 nurses in South Sumatra. During the activity, the participants were very enthusiastic in listening, discussing with resource persons, and doing simulations well. There is an increase in documentation ability before and after the documentation training using SIMPACA is carried out. SIMPACA is proven to be effective in improving nurses' documentation skills and reducing nurses' time in documenting their nursing care to patients. There is a need for further development of SIMPACA because it must adapt to the needs of the hospital.

Keywords

Documentation, Nurses, SIMPACA application

Full Text:

PDF

References

Adam, A. (2016). sistem informasi manajemen rumah sakit dalam peningkatan mutu pelayanan di Rumah Sakit Umum Daerah Pangkep (Studi kualitatif di Rumah Sakit Umum Daerah Pangkep). Media Komunitas Kesehatan FKM UPRI Makassar, 3(2).

Akhu‐Zaheya, L., Al‐Maaitah, R., & Bany Hani, S. (2018). Quality of nursing documentation: Paper‐based health records versus electronic‐based health records. Journal of clinical nursing, 27(3-4), e578-e589. https://doi.org/10.1111/jocn.14097

Astarini, M. I. A. (2018). Literatur review: Efektivitas modifikasi dokumentasi keperawatan (A literature review: Effectivities of nursing documentation modification). Jurnal Ners LENTERA, 6(1), 42-48.

Atasoy, H., Greenwood, B. N., & McCullough, J. S. (2019). The digitization of patient care: a review of the effects of electronic health records on health care quality and utilization. Annual review of public health, 40, 487-500. https://doi.org/10.1146/annurev-publhealth-040218-044206

Atmanto, A. P., Aggorowati, A., & Rofii, M. (2020). Efektivitas pedoman pendokumentasian diagnosa dan intervensi keperawatan berbasis android terhadap peningkatan mutu dokumentasi keperawatan di ruang rawat inap. Jurnal Keperawatan dan Kesehatan Masyarakat Cendekia Utama, 9(1), 83-92. https://doi.org/10.31596/jcu.v9i1.517

Baumann, L. A., Baker, J., & Elshaug, A. G. (2018). The impact of electronic health record systems on clinical documentation times: a systematic review. Health Policy, 122(8), 827-836. https://doi.org/10.1016/j.healthpol.2018.05.014

Chand, S., & Sarin, J. (2014). Electronic nursing documentation. International Journal of Information Dissemination and Technology, 4(4), 328–331.

Dewi, A. (2019). Dampak penerapan sistem pencatatan keperawatan elektronik: Literatur review. Jurnal Surya, 11(03), 40-46. https://doi.org/10.38040/js.v11i03.50

Dwiantoro, L., Keliat, B. A., Bachtiar, A., & Hariyati, R. T. S. (2015). Hubungan antara perilaku merawati tim pelayanan dengan capaian indikator program gizi. Jurnal Keperawatan Komunitas, 3(1), 29-36.

Erna, N. K., & Dewi, N. L. P. T. (2020). Kepatuhan perawat dalam melakukan dokumentasi asuhan keperawatan. Holistic Nursing and Health Science, 3(1), 17-23. https://doi.org/10.14710/hnhs.3.1.2020.17-23

Firouzeh, M. M., Jafarjalal, E., Emamzadeh Ghasemi, H. S., Bahrani, N., & Sardashti, S. (2017). Evaluation of vocal-electronic nursing documentation: A comparison study in Iran. Informatics for Health and Social Care, 42(3), 250-260. https://doi.org/10.1080/17538157.2016.1178119

Hariyati, R. T. S., Delimayanti, M. K., & Widyatuti, T. (2011). Developing protototype of the nursing management information system in Puskesmas and hospital , Depok Indonesia. African Journal of Business Management, 5(22), 9051–9058. https://doi/org/10.5897/AJBM11.2356

Hariyati, R. T. S., Yani, A., Eryando, T., Hasibuan, Z., & Milanti, A. (2016). The effectiveness and efficiency of nursing care documentation using the SIMPRO model. International journal of nursing knowledge, 27(3), 136-142. https://doi.org/10.1111/2047-3095.12086

Hariyati, T. S., Kobayashi, N., Sahar, J., Nuraini, T., Solihin, J., & Sri, T. (2018). Simplicity and completeness of nursing process satisfaction using nursing management information system at the public health service “X” Indonesia. International Journal of Caring Sciences, 11(2), 1034-1042.

Harsono, A. (2015). Analisis implementasi sistem informasi manajemen rumah sakit umum daerah (SIM-RSUD) terintegrasi di Provinsi Kalimantan Barat. Jurnal Eksplora Informatika, 5(1), 11-22.

Hidayat, A. A. A. (2008). Pengantar konsep dasar keperawatan (2nd ed.). Salemba Medika.

Koerniawan, D., Daeli, N. E., & Elizabeth, N. (2019). Pendampingan implementasi proses keperawatan: Nanda 2015-2020, SDKI 2017, NOC, dan NIC kepada preseptor klinik ners. Jurnal Abdimas Musi Charitas, 3(2), 47-55.

McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3), 491–501. https://doi.org/10.1111/jonm.12727

Meidianta, A. C., & Milkhatun, M. (2020). Hubungan antara pelatihan proses keperawatan dengan pengetahuan perawat tentang penerapan Standar Diagnosis Keperawatan Indonesia di RSUD Samarinda. Borneo Student Research (BSR), 1(2), 647-651.

Nguyen, L., Wickramasinghe, N., Redley, B., Haddad, P., Muhammad, I., & Botti, M. (2017). Exploring nurses’ reactions to electronic nursing documentation at the point of care. Information Technology & People, 30(4), 809–831. https://doi.org/10.1108/ITP-10-2015-0269

PPNI. (2016). Standar diagnosis keperawatan Indonesia: Definisi dan indikator diagnostik. Edisi 1. Jakarta: DPP PPNI.

PPNI. (2017). Standar intervensi keperawatan Indonesia: Definisi dan tindakan keperawatan. Edisi 1. Jakarta: DPP PPNI.

PPNI. (2018). Standar luaran keperawatan Indonesia: Definisi dan kriteria hasil keperawatan. Edisi 1. Jakarta: DPP PPNI.

PPNI. (2019). Standar luaran keperawatan Indonesia: Definisi dan kriteria hasil keperawatan. Edisi 1. Jakarta: DPP PPNI.

Saraswasta, I. W. G., & Hariyati, R. T. S. (2018). The implementation of electronic-based nursing care documentation on quality of nursing care: A literature review. International Journal of Nursing and Health Services (IJNHS), 1(2), 19-31. https://doi.org/10.35654/ijnhs.v1i2.23

Schnall, R., Cimino, J. J., & Bakken, S. (2012). Development of a prototype continuity of care record with context-specific links to meet the information needs of case managers for persons living with HIV. International journal of medical informatics, 81(8), 549-555. https://doi.org/10.1016/j.ijmedinf.2012.05.002

Setyaningrum, I., Hariyati, R. T. S., & Novieastari, E. (2016). Peningkatan kelengkapan dokumentasi dan kepuasan perawat pada pengawasan hospital acquired infections (HAIs) berbasis komputer. Jurnal Keperawatan Indonesia, 19(1), 33-40. https://doi.org/10.7454/jki.v19i1.436

Siswanto, L. H., Hariyati, R. T. S., & Sukihananto, S. (2013). Faktor-faktor yang berhubungan dengan kelengkapan pendokumentasian asuhan keperawatan. Jurnal Keperawatan Indonesia, 16(2), 77-84. https://doi.org/10.7454/jki.v16i2.5

Suganda & Hariyati, T., & Hariyati, R. T. S. (2020). Perbandingan kualitas dokumentasi keperawatan berbasis elektronik dan berbasis kertas: Study literature. Holistik Jurnal Kesehatan, 14(1), 17-28. https://doi.org/10.33024/hjk.v14i1.2085

Sulastri, S., & Sari, N. Y. (2018). Metode Pendokumentasian elektronik dalam meningkatkan kualitas pelayanan keperawatan. Jurnal Kesehatan, 9(3), 497. http://dx.doi.org/10.26630/jk.v9i3.987

Supratti, S., & Ashriady, A. (2018). Pendokumentasian standar asuhan keperawatan di Rumah Sakit Umum Daerah Mamuju. Jurnal Kesehatan Manarang, 2(1), 44-51. https://doi.org/10.33490/jkm.v2i1.13

Tarwoto, & Wartonah. (2011). Kebutuhan dasar manusia dan proses keperawatan (4th ed.). Salemba Medika.

Timur, C. N., Arso, S. P., & Ardani, M. H. (2020). Inovasi pengembangan sistem infomasi untuk meningkatkan kepatuhan perawat dalam pencegahan pasien jatuh. Jurnal Kepemimpinan Dan Manajemen Keperawatan, 3(1), 37. https://doi.org/10.32584/jkmk.v3i1.545

Yanti, R. I., & Warsito, B. E. (2013). Hubungan karakteristik perawat, motivasi, dan supervisi dengan kualitas dokumentasi proses asuhan keperawatan. Jurnal Managemen Keperawatan, 1(2), 107–114.

Zendrato, M. V., & Hariyati, R. T. S. (2018). Optimalisasi pengelolaan asuhan keperawatan di instalasi rawat jalan Rumah Sakit X. Jurnal Persatuan Perawat Nasional Indonesia (JPPNI), 2(2), 85-99. http://dx.doi.org/10.32419/jppni.v2i2.86

DOI: https://doi.org/10.26905/abdimas.v7i2.6837