Optimalisasi Perencanaan, Pengorganisasian, dan Pelaksanaan Dokumentasi Implementasi Asuhan Keperawatan Melalui Sistem CARE TAG di RS X Kabupaten Jember - Choiria Firdatul Ulfah; Ardho Yuwono Wisnugati; Tantut Susanto; Debie Saktyana Iriawandani (Universitas Dirgantara Marsekal Suryadarma, 2026)
Pendokumentasian asuhan keperawatan merupakan indikator penting mutu pelayanan rumah sakit, namun masih sering mengalami ketidaklengkapan dan inkonsistensi. Audit internal di RS X Kabupaten Jember menunjukkan rendahnya kepatuhan dokumentasi, khususnya pada komponen SBAR, edukasi pasien, verifikasi oleh dokter penanggung jawab pasien (DPJP), dan instruksi profesional pemberi asuhan (PPA). Penelitian ini bertujuan menganalisis efektivitas penerapan sistem CARE-TAG (Clinical Assessment & Recording Evaluation – Training & Guidance) dalam meningkatkan kepatuhan dokumentasi keperawatan. Penelitian ini menggunakan desain pre–post intervention tanpa kelompok kontrol dengan pendekatan deskriptif. Subjek penelitian melibatkan 17 perawat di Ruang Catleya RS X yang dipilih melalui total sampling. Intervensi CARE-TAG dilakukan melalui in house training, penggunaan checklist monitoring harian, supervisi langsung, self-assessment, serta umpan balik real-time. Evaluasi dilakukan selama empat hari terhadap kelengkapan dokumentasi SBAR, instruksi PPA, edukasi pasien, discharge planning, dan verifikasi DPJP. Hasil penelitian menunjukkan peningkatan kepatuhan dokumentasi, dengan kelengkapan SBAR meningkat dari 61,54% menjadi 100% dan instruksi PPA mencapai kepatuhan penuh sejak hari ketiga. Dokumentasi edukasi pasien dan discharge planning mencapai 84,6%, sementara verifikasi DPJP masih rendah. CARE-TAG efektif meningkatkan kepatuhan dokumentasi keperawatan dalam jangka pendek dan memerlukan dukungan kolaborasi interprofesional serta integrasi teknologi untuk keberlanjutan. Nursing care documentation is a key indicator of hospital service quality; however, it often remains incomplete and inconsistent. An internal audit at Hospital X in Jember Regency revealed low compliance in nursing documentation, particularly in SBAR components, patient education, verification by attending physicians, and professional caregiver instructions. This study aimed to analyze the effectiveness of the CARE-TAG (Clinical Assessment & Recording Evaluation – Training & Guidance) system in improving nursing documentation compliance. This study employed a pre–post intervention design without a control group using a descriptive approach. The participants were 17 nurses working in the Catleya Ward of Hospital X, recruited through total sampling. The CARE-TAG intervention included in-house training, daily monitoring checklists, direct supervision, self-assessment, and real-time feedback. Documentation compliance was evaluated over four consecutive days, focusing on SBAR documentation, professional caregiver instructions, patient education, discharge planning, and physician verification. The findings showed improved documentation compliance, with SBAR completeness increasing from 61.54% to 100% and professional caregiver instructions achieving full compliance by the third day. Documentation of patient education and discharge planning reached 84.6%, whereas physician verification remained low. CARE-TAG was effective in improving short-term nursing documentation compliance and requires strengthened interprofessional collaboration and health information technology integration to ensure sustainability