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, 2026)
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.