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All Journal PROSIDING SEMINAR NASIONAL Jurnal Keperawatan Indonesia JURNAL ILMIAH KESEHATAN KEPERAWATAN Jurnal Manajemen Keperawatan Jurnal Keperawatan Komunitas Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing) Juiperdo Jurnal NERS Jurnal Keperawatan Muhammadiyah Nursing Current : Jurnal Keperawatan Jurnal Keperawatan Komprehensif (Comprehensive Nursing Journal) International Journal of Nursing and Health Services (IJNHS) Journal of Nursing Care Jurnal Ilmu Kesehatan Bhakti Husada: Health Sciences Journal Poltekita : Jurnal Ilmu Kesehatan Jurnal Manajemen dan Administrasi Rumah Sakit Indonesia (MARSI) Real in Nursing Journal Jurnal JKFT Jurnal Kesehatan Karya Husada Syntax Idea Jurnal Persatuan Perawat Nasional Indonesia (JPPNI) Journal of Telenursing (JOTING) Indonesian Journal of Global Health research Jurnal Menara Medika MAHESA : Malahayati Health Student Journal Humantech : Jurnal Ilmiah Multidisiplin Indonesia Journal of International Conference Proceedings DUNIA KEPERAWATAN: JURNAL KEPERAWATAN DAN KESEHATAN Jurnal Kedokteran Meditek Holistik Jurnal Kesehatan Journal of Global Research in Public Health Jurnal Info Kesehatan
Rr Tutik Sri Hariyati
Faculty Of Nursing, Universitas Indonesia
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Electronic-based Nursing Documentation: Literature Review Gorean, Grace Irma; Hariyati, Rr. Tutik Sri; Handiyani, Hanny
Jurnal Ilmiah Perawat Manado (Juiperdo) Vol 11 No 02 (2023): DESEMBER
Publisher : POLITEKNIK KESEHATAN KEMENTERIAN KESEHATAN MANADO

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47718/jpd.v11i2.2166

Abstract

Pendahuluan Pendokumentasi keperawatan bertujuan untuk menunjukkan akuntabilitas dan tanggung jawab tindakan perawat. Dokumentasi yang tidak memadai mempengaruhi kesehatan, keselamatan pasien serta kualitas pelayanan. Pendokumentasi keperawatan elektronik adalah system catatan yang menggunakan komputer untuk mengetahui tindakan yang dilakukan oleh perawat dalam menjalankan proses keperawatan. Tujuan Memberikan gambaran secara umum mengenai manfaat pendokumentasi keperawatan berbasis elektronik. Metode menggunakan metode literature review dari berbagai jenis metode penelitian, termasuk studi cross sectional, literatur review, desain restrospektif komparatif, kuasi eksperimental, metode pendekatan kualitas pra dan pasca regresi logistic multilevel univariat dan multivariat, pengembangan kusioner, tinjauan Pustaka prisma. Hasil Analis jurnal didapatkan bahwa pendokumentasian keperawatan berbasis elektronik memiliki manfaat dalam meningkatkan keakuratan dan kecepatan dalam mengelolah informasi, efektifitas pengelolaan data pasien serta meningkatkan mutu pelayanan keperawatan dan keselamatan pasien. Kesimpulan dari segi efisiensi, efektifitas ,fokus pasien dan akurasi waktu dokumentasi keperawatan berbasis elektronik lebih berkualitas dibandingkan dokumentasi berbasis kertas.
Optimalisasi fungsi actuating kepala ruangan dalam supervisi dokumentasi asuhan keperawatan di rumah sakit Perdana, Riska Rusfita; Afriani, Tuti; Wirdani, Andi Wilda; Hariyati, Rr Tutik Sri; Harpendewisasmita, Harpendewisasmita; Kuntarti, Kuntarti
Holistik Jurnal Kesehatan Vol. 19 No. 11 (2026): Volume 19 Nomor 11
Publisher : Program Studi Ilmu Keperawatan-fakultas Ilmu Kesehatan Universitas Malahayati

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33024/hjk.v19i11.1751

Abstract

Background: Electronic Medical Records (EMR) plays a crucial role in nursing care, serving as legal evidence, a means of interprofessional communication, and a benchmark for service quality. Ward heads, as first-line managers, hold a crucial responsibility in ensuring documentation is carried out according to standards. Purpose: To optimize the ward head's driving function in overseeing nursing care documentation in hospitals. Method: This study used a case study approach conducted in the Intermediate Ward of Jantung dan Pembuluh Darah Harapan Kita Hospital. Data were collected through observation, interviews with ward heads and nurses, and questionnaires distributed to 30 nurses. The analysis was based on Marquis & Huston's 2021 management function theory and Kurt Lewin's theory of change. Problems were analyzed using the fishbone method and Priority Setting Guidelines (PSG) assessment to determine priority interventions. Results: Nurses' compliance with EMR documentation standards improved after socialization. Furthermore, ward heads' understanding of the importance of reflection-based clinical supervision also improved. 28.9% of respondents stated that ward heads always supervise nursing care documentation, 27.7% stated that supervision is frequent, 20.5% stated that supervision is rare, and 22.9% stated that ward heads never supervise documentation. Conclusion: Interventions through educational and reflective supervision have proven effective in improving the quality of EMR-based nursing documentation. Suggestion: Ongoing training for ward heads and integration of supervision forms into the hospital's digital system are needed to ensure the sustainability of the intervention.   Keywords: Driving Function; Hospital; Nursing Care Documentation; Supervision; Ward Head.   Pendahuluan: Dokumentasi asuhan keperawatan elektronik/ Electronic Medical Record (EMR) memiliki peran krusial dalam pelayanan keperawatan, baik sebagai bukti legal, media komunikasi antarprofesi, maupun tolak ukur mutu layanan. Kepala ruangan sebagai manajer lini pertama memegang tanggung jawab penting dalam memastikan dokumentasi dilakukan sesuai standar. Tujuan: Untuk mengoptimalisasi fungsi actuating kepala ruangan dalam supervisi dokumentasi asuhan keperawatan di rumah sakit. Metode: Penelitian ini menggunakan pendekatan case study yang dilaksanakan di ruang Intermediate Ward Rumah Sakit Jantung dan Pembuluh Darah Harapan Kita (RSJPDHK). Data dikumpulkan melalui observasi, wawancara kepala ruangan, dan perawat, serta penyebaran kuesioner kepada 30 perawat pelaksana. Analisis dilakukan berdasarkan teori fungsi manajemen Marquis & Huston tahun 2021 dan teori perubahan Kurt Lewin. Masalah dianalisis menggunakan metode fishbone dan scoring Priority Setting Guideline (PSG) untuk menentukan intervensi prioritas. Hasil: Terdapat peningkatan kepatuhan perawat terhadap standar dokumentasi EMR setelah sosialisasi dilaksanakan. Selain itu, pemahaman kepala ruangan terhadap pentingnya supervisi klinis berbasis refleksi juga meningkat. Didapatkan 28.9% responden menyatakan bahwa kepala ruangan selalu melakukan supervisi dokumentasi asuhan keperawatan, 27.7% menyatakan bahwa supervisi dilakukan sering, 20.5% menyatakan bahwa supervisi hanya jarang dilakukan, dan 22.9% menyatakan bahwa kepala ruangan tidak pernah melakukan supervisi dokumentasi Simpulan: Intervensi melalui supervisi edukatif dan reflektif terbukti efektif dalam meningkatkan kualitas dokumentasi keperawatan berbasis EMR. Saran: Diperlukan pelatihan berkelanjutan bagi kepala ruangan dan integrasi formulir supervisi ke dalam sistem digital rumah sakit untuk menjamin keberlanjutan intervensi.   Kata Kunci: Dokumentasi Asuhan Keperawatan; Fungsi Actuating; Kepala Ruangan; Rumah Sakit; Supervisi.
The Effectiveness of Preceptorship Programs in Improving Clinical Competence among Novice Nurses: A Systematic Review Wea, Maria; Hariyati, Rr. Tutik Sri; Handiyani, Hanny; Wildani, Andi Amalia
Nursing Current: Jurnal Keperawatan Vol. 13 No. 2 (2025): December
Publisher : Universitas Pelita Harapan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.19166/nc.v13i2.10300

Abstract

The transition period for new nurses is often characterized by adaptation-related stress, limited clinical experience, and insufficient supervision. Preceptorship offers structured support that helps accelerate competency development and enhance clinical readiness for practice. To evaluate the effectiveness of preceptorship programs in improving clinical competence in novice nurses.  A systematic search was conducted in PubMed, ScienceDirect, ProQuest, and Google Scholar from August 2019 to April 2025, following the PRISMA 2020 guidelines and registered PROSPERO protocol. This review included quantitative studies involving new nurses who received structured preceptorship interventions with clinical competency as the primary outcome. Eligible study designs comprised randomized controlled trials, quasi-experimental studies, uncontrolled pre–post trials, and cross-sectional surveys. Qualitative studies, student-based programs, and orientations without preceptors were excluded. Two reviewers independently conducted study selection, data extraction, and methodological quality appraisal using the JBI critical appraisal tools. The findings were synthesized narratively. Ten studies consistently demonstrated that preceptorship programs improved clinical competence, confidence, and readiness for practice. Eight studies reported significant improvements (p < 0.05). Effective programs included individualized supervision, structured feedback, and standardized competency assessments. Critical success factors included preceptor readiness, continuity of preceptorship, organizational support, and reduced transition shock. The findings indicate that well-structured preceptorship programs can enhance the clinical competence and self-confidence of novice nurses. Healthcare institutions are encouraged to adopt standardized preceptorship frameworks, allocate adequate resources, and provide ongoing training and support for preceptors to strengthen practice readiness, improve quality of care, and promote nurse retention. 
Co-Authors Abdiansyah, Baskoro Achmad Nizar Hidayanto Achmad Sigit S Achmad Syaifudin Adang Bachtiar Afiyanti, Efi Agrina Agrina Aldri Frinaldi Alpan Habibi Amir, Haeril Andri Setiya Wahyudi Annisa Rahmi Galleryzki Asmara, Amelia Astuty, Mazly Aziz, Herawani Azizah, Yuni Bela Pertiwi Budi Anna Keliat Candra Panji Asmoro, Candra Panji Cicilia Ika Wulandari Dedi Damhudi Deny Gunawan Desnita Fitri Desyi Prana Napitupulu Dewi Gayatri Dewi Irawaty Dewi Sartika Dewi Wulandari Dewi, Laurentia Diantha Soemantri Diki Armansyah Djarang, Lilyance Djuma, Elviera Dwiantoro, Luky Dwiantoro, Luky Efi Afifah Elly Nurachmah Enie Novieastari Erwin Erwin Fadllah, Ellya - Fichara, Sitta Diani Friska Friska Gad Datak Gorean, Grace Irma Hanny Handiyani Harpendewisasmita, Harpendewisasmita Hendra Dwi Cahyono Hening Pujasari Hernawati, Lestari I Wayan Gede Saraswasta Indraswari, Anies Dewi Wirati Junaiti Sahar Keumalasari, Keumalasari Krisna Yetti Krisna Yetti Krisna Yetti Krisna Yetti Kuntarti L. M. Harmain Siswanto La Ode Abdul Rahman Lia Dwi Jayanti Lia Dwi Jayanti Made Sumarwati Masfuri - Mediati, Ati Surya Mediawati, Ati Surya Meilina, Ratna Merduati, Rona Cahyantari Merduaty, Rona Cahyantari Mery Anglelia Sirait Moh. Heri Kurniawan Muhamad Rofi’i Muhamad Rofi’i Mulia Hakam Nasri, Khairul Nasution, Lina Anisa Nilasari, Putri Novy Helena Chatarina Daulima Nugraha, Susiana Nur Wulan Nurchayati, May Nurdiana Nurdiana Nurdiana Nurdiana Nuridha Fauziyah Oktaviarini, Eva Perdana, Riska Rusfita Pratiwi, Leny Puguh Widiyanto Purwaningsih, Sri puspita, vema tiyas Putri Nilasari Putro, Prasetyo Adi Wibowo Resty, Dian Eka Retnoningtyas, Wahyu Kusumadi Rizany, Ichsan Rona Cahyantari Merduaty Rozalinda Rozalinda Rumentalia Sulistini Santi Wahyuningsih, Santi Sekarsari, Rita Setiawati, Deni Setyowati , Setyowati Setyowati Setyowati Setyowati, Setyowati Simatupang, Yesi Juniarta Siti Anisah Siti Anisah Sudaryati Sudaryati Sugihasih, Sugihasih Sukihananto Sukihananto Sukihananto, Sukihananto Susilowati, Margareta Syahrul Tuba Tori Rihiantoro Trevino A. Pakasi Tri Ilmiah Fattah Triaswati, Rusmai Tuti Afriani Tuti Nuraini Umi Fatmawati UMI FATMAWATI Verdiansyah, Rio Wahyuni, Tyas Wea, Maria Widasari Sri Gitarja, Widasari Sri Wildani, Andi Amalia Wirdani, Andi Wilda Wulandari, Rista Tri Yiyin Qamariah Takaredas Yulia Yulia Yuyun Tafwidhah Zakiyyah, Naadiyah