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Inisiasi Pengelolaan Metode Pemberian Asuhan Keperawatan Primer di RS X Tulende, Alfani; Handiyani, Hanny; Wildani, Andi Amalia; Harpendewisasmita, Harpendewisasmita
Journal of Telenursing (JOTING) Vol 6 No 2 (2024): Journal of Telenursing (JOTING)
Publisher : Institut Penelitian Matematika, Komputer, Keperawatan, Pendidikan dan Ekonomi (IPM2KPE)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31539/joting.v6i2.13044

Abstract

This study aims to analyze and design the implementation of change through the initiation of management of primary nursing care delivery methods. The method used is a case report with interviews, observations, document reviews, and questionnaire surveys as well as problem analysis using fishbone diagrams. The results of the analysis showed that the method of providing nursing care in the inpatient room was not optimal, so through a change approach using the Kurt Lewin;s Change Model, the initiation of management of primary nursing care delivery methods was carried out. In conclusion, optimizing nursing care delivery methods through the implementation of primary nursing care management methods with a systematic and structured management approach has the potential to improve the quality of nursing services. Keywords: Initiation Of Management, Kurt Lewin's Change Model, Primary Nursing Method
Initiation of the Development of a Bedside Handover Guideline in the Emergency Department of Hospital X Joaquin, Hinoveva Natalia; Handiyani, Hanny; Wilda, Andi Amalia; Harpendewisasmita, Harpendewisasmita
Indonesian Journal of Global Health Research Vol 7 No 5 (2025): Indonesian Journal of Global Health Research
Publisher : GLOBAL HEALTH SCIENCE GROUP

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/ijghr.v7i5.6869

Abstract

Emergency Department (ER) services are highly complex and carry significant risks to patient safety. Effective communication during the handover process is critical to improving patient safety and care quality. Bedside handover is a strategic form of communication between healthcare workers, ensuring that vital patient information—such as vital signs and urgent care needs—is conveyed accurately and directly, with involvement from both patients and families. The ISBAR communication tool provides a clear structure that helps reduce the risk of miscommunication. Objective to develop a guideline that serves as a consistent reference for nurses in performing bedside handover, fostering a culture of safety and high-quality care at Hospital X. Method: This study used a case report approach with both qualitative and quantitative methods to examine the nursing service system at Hospital X. Data were collected through interviews, document reviews, observations, and questionnaires, and analyzed using the nursing management function approach: planning, organizing, directing, and controlling. Questionnaires were distributed to unit leaders, unit coordinators, and all staff nurses working in Room X, with a total of 48 respondents with total sampling. In the Unfreezing Phase, many ER nurses resisted the bedside handover method, perceiving it as time-consuming and burdensome. Observations revealed continued reliance on traditional handover methods. In the Changing Phase, a Plan of Action (POA) was developed, including drafting supervision guidelines, conducting socialization, and evaluating bedside handover implementation. In the Refreezing Phase, bedside handover was expected to become standard practice, though implementation was limited by time constraints. The implementation of bedside handover in the ER, guided by Lewin’s Change Theory and structured through ISBAR, is a strategic step to ensure care continuity and improve patient safety.
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.