Eksplorasi Faktor-faktor yang Mempengaruhi Tingkat Praktik Dokumentasi Keperawatan: Scoping Review
DOI:
https://doi.org/10.32583/pskm.v15i4.3683Keywords:
dokumentasi, perawat, praktikAbstract
Dokumentasi keperawatan merupakan komponen sangat penting untuk praktik keperawatan, mendukung perawatan berkualitas, komunikasi antarprofesi, dan pengambilan keputusan klinis. berbagai faktor, seperti beban kerja, rasio perawat-pasien, pengetahuan, dan sikap perawat, sering kali memengaruhi kualitas dokumentasi. Penelitian ini bertujuan untuk mengeksplorasi faktor-faktor yang memengaruhi praktik dokumentasi keperawatan melalui scoping review. Penelitian dilakukan melalui scoping review dengan kriteria kelayakan: artikel akademis dari ProQuest, ScienceDirect, PubMed, Ebsco, dan Scopus, terbit pada 2020–2024, berbahasa Inggris, populasi penelitian adalah perawat, dan dampak yang diukur adalah dokumentasi keperawatan. Proses seleksi mencakup identifikasi, skrining, kelayakan, dan inklusi. Kata kunci “Nurse” AND, “Documentation” AND” Practice”. Dari 534 artikel awal, 6 artikel dianalisis dengan pendekatan deskriptif untuk mengidentifikasi faktor- faktor yang mempengaruhi praktik dokumentasi keperawatan. Artikel berasal dari Norwegia, Zimbabwe, Pakistan, Nigeria, dan Ethiopia, menggunakan metode cross-sectional, audit klinis, dan analisis kualitatif. Faktor yang mempengaruhi dokumentasi meliputi: Faktor Individual: Pengetahuan, sikap, pengalaman kerja, usia, tingkat pendidikan. Faktor Organisasi: Beban kerja, rasio perawat-pasien, pelatihan tidak memadai, Faktor Sumber Daya: Ketersediaan lembar dokumentasi, waktu, dan infrastruktur. Faktor individu, organisasi, dan sumber daya mempengaruhi dokumentasi keperawatan. Intervensi berbasis pelatihan, kebijakan, dan teknologi diperlukan agar meningkatkan kualitas dokumentasi lebih baik. Penelitian lebih lanjut diperlukan untuk mengimplementasikan intervensi ini.
References
Abduh M, et al. (2023). Survey Design: Cross Sectional dalam Penelitian Kualitatif. Jurnal Pendidikan Sains Dan Komputer, 3(1), 31–38. https://doi.org/https://doi.org/10.47709/jpsk.v3i01.1955 Survey
Apriliani, I. M., Purba, N. P., Dewanti, L. P., Herawati, H., & Faizal, I. (2022). Stunting Risk Factors in Children Under Five in Indonesia: A Scoping Review. The Indonesian Journal of Health Promotion, 5(6), 654–661.
Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology: Theory and Practice, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616.
Bolado, G. N., Ayalew, T. L., Feleke, M. G., Haile, K. E., & Geta, T. (2023). Documentation practice and associated factors among nurses working in public hospitals in Wolaita Zone, Southern Ethiopia. BMC Nursing, 22, 1–11. https://doi.org/https://doi.org/10.1186/s12912-023-01490-8
Dianna, D. N. (2020). Dasar-Dasar Penelitian Akademik : Analisis Data Kualitatif dan Kuantitatif. Jurnal Akuntansi, March, 1–10. https://www.researchgate.net/publication/340063433
Dickerson, J. E. (2023). Clinical audit, quality improvement and data quality. Anaesthesia & Intensive Care Medicine, 24(8), 486–489. https://doi.org/https://doi.org/10.1016/j.mpaic.2023.05.005
Hanžek, K. (2024). Nursing documentation as important part of the medical documentation. Lijecnicki Vjesnik, 2024(1–2), 62–66. https://doi.org/10.26800/LV-146-1-2-8
Hussain M*, Saddique H, J. R. (2024). Knowledge Attitude And Practise Of Nurses Regrading Nursing Documentation. Biol. Clin. Sci. Res. J., 1–5. https://doi.org/https://doi.otg/10.54112/bcsrj.v2024iI.1393
İlaslan, E., Adıbelli, D., Teskereci, G., & Üzen Cura, Ş. (2023). Development of nursing students’ critical thinking and clinical decision-making skills. Teaching and Learning in Nursing, 18(1), 152–159. https://doi.org/https://doi.org/10.1016/j.teln.2022.07.004
Jones, T. L. (2021). Nursing care processes. In Nurses Contributions to Quality Health Outcomes (pp. 157–176). Springer International Publishing. https://doi.org/10.1007/978-3-030-69063-2_9
Kaihlanen, A. M., Gluschkoff, K., Saranto, K., Kinnunen, U. M., & Heponiemi, T. (2021). The associations of information system’s support and nurses’ documentation competence with the detection of documentation-related errors: Results from a nationwide survey. Health Informatics Journal, 27(4), 1–12. https://doi.org/10.1177/14604582211054026
Kassie, S. Y., Demsash, A. W., Chereka, A. A., & Damtie, Y. (2023). Medical documentation practice and its association with knowledge, attitude, training, and availability of documentation guidelines in Ethiopia, 2022. A systematic review and meta-analysis. Informatics in Medicine Unlocked, 38(March), 101237. https://doi.org/10.1016/j.imu.2023.101237
Koten E, B, E. a. (2021). Optimalisasi Kualitas Dokumentasi Asuhan Keperawatan Dengan Pendekatan SOAP di Rawat jalan: Pilot Study. Journal Of Telenursing(JOTING), 3, 252–265. https://doi.org/https://doi.org/10.31539/joting.v3i1.2229
Moldskred, P. S., Snibsoer, A. K., & Espehaug, B. (2021). Improving the quality of nursing documentation at a residential care home: a clinical audit. BMC Nursing, 20(1). https://doi.org/10.1186/s12912-021-00629-9
Molla, F., Temesgen, W. A., Kerie, S., & Endeshaw, D. (2024). Nurses’ Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study. SAGE Open Nursing, 10. https://doi.org/10.1177/23779608241227403
Mutema, E., Haruzivish, C., & Mhlanga, M. (2024). Structural and Process Factors Influencing Documentation Practice in Private and Public Labour Wards of Parirenyatwa Maternity Hospital, Zimbabwe. American Journal of Nursing Science, 13(4), 86–97. https://doi.org/10.11648/j.ajns.20241304.13
Ngozi, A. L., Dioso, R. I., & Anyebe, E. E. (2024). Factors Influencing Documentation in Nursing Care by Nurses at the Federal Medical Centre, Apir, Benue State, Nigeria. Malaysian Journal of Nursing, 16(2), 63–73. https://doi.org/10.31674/mjn.2024.v16i02.007
Peters, M. D. J., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews. International Journal of Evidence-Based Healthcare, 13(3), 141–146. https://doi.org/10.1097/XEB.0000000000000050
Peters, M. D. J., Godfrey, C., McInerney, P., Khalil, H., Larsen, P., Marnie, C., Pollock, D., Tricco, A. C., & Munn, Z. (2022). Best practice guidance and reporting items for the development of scoping review protocols. JBI Evidence Synthesis, 20(4), 953–968. https://doi.org/10.11124/JBIES-21-00242
Rahmatin, D. A., Dianah, H. S., & ... (2024). Sistem Dokumentasi Asuhan Keperawatan Dalam Upaya Peningkatan Mutu Manajemen Keperawatan. Jurnal Kesehatan Tambusai, 5, 1400–1409. http://journal.universitaspahlawan.ac.id/index.php/jkt/article/view/24369
Sumarni, T., Siwi, A. S., R, A. N., & Suhendro, A. (2022). Penerapan Dokumentasi Keperawatan Menggunakan 3S (SDKI, SLKI, SIKI) di RSI Banjarnegara. Jurnal Pengabdian Masyarakat, 1(4), 110–118. https://doi.org/10.35960/pimas.v1i4.891
Tasew, H., Mariye, T., & Teklay, G. (2019). Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Research Notes, 12(1), 1–6. https://doi.org/10.1186/s13104-019-4661-x
Wahyuliati Tri, N. V. R. (2023). Efektivitas Pelatihan dan Supervisi terhadap Peningkatan Kualitas Pendokumentasian Asuhan Keperawatan : Literature Review. The Indonesian Journal of Health Promotion, 6(7), 1250–1258.
Widiasih, R., Susanti, R. D., Mambang Sari, C. W., & Hendrawati, S. (2020). Menyusun Protokol Penelitian dengan Pendekatan SETPRO: Scoping Review. Journal of Nursing Care, 3(3), 171–180. https://doi.org/10.24198/jnc.v3i3.28831
Yuliastanti, Y., & Wulandari, C. I. (2025). Dokumentasi Keperawatan : Literature Review. 9(April), 1637–1648.
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