FAKTOR–FAKTOR YANG MEMPENGARUHI KEPATUHAN PERAWAT DALAM PENDOKUMENTASIAN ASUHAN KEPERAWATAN PADA ELEKTRONIK REKAM MEDIS DI RSUD PAMEUNGPEUK GARUT

Abstract

Documentation is written evidence of a nurse and other careprovider professionals to avoid all kinds of demands, which are arranged for safer nursing care services. By 2024, all healthcare facilities will be required to use electronic medical records (EMR). One of the benchmarks of nurse compliance in documenting is good knowledge, professional attitude, high motivation, and supervision from the head of the room in stages to support access and continuity of services. This study aims to analyze the relationship between nurse characteristics and factors that affect nurse compliance in documenting nursing care in RME at RSUD Pameungpeuk Garut. This study used a cross-sectional approach analytical survey design, with a sample of 94 people. Using primary data (questionnaire of nurse characteristics, knowledge, attitudes, motivation, and supervision of the head of the room). Data analysis using Chi-Square followed by multivariate linear regression analysis. The results showed a relationship between the supervision of the head of the room (p = 0.027) in compliance with nursing care documentation in RME. The results of the multivariate analysis showed that the supervision of the head of the room was the most dominant variable of the regression coefficient (b = 0.252). The study concluded that there was a relationship between the supervision of the head of the room in compliance with the documentation of nursing care in RME, that nurses who were often supervised would experience an increase in documentation compliance by 25.2% better, compared to nurses who were not supervised by the head of the room.