ABSTRAK Analisis Situasi: Pengodean penyakit, khususnya external cause (penyebab luar) dalam rekam medis pasien gawat darurat, sangat esensial namun sering terkendala akurasinya karena kurang optimalnya kelengkapan dokumentasi asuhan keperawatan oleh perawat. Permasalahan ini menuntut peningkatan kompetensi manajemen informasi pada calon tenaga kesehatan. Tujuan: Pengabdian ini bertujuan meningkatkan pemahaman mahasiswa Profesi Ners UNJAYA tentang pentingnya manajemen informasi asuhan keperawatan dalam mendukung akurasi diagnosis cedera luar. Metode: Kegiatan dilaksanakan melalui penyuluhan berbasis transfer ilmu pengetahuan dan teknologi. Mitra Sasaran: Mitra kegiatan ini adalah 51 mahasiswa Profesi Ners UNJAYA. Evaluasi peningkatan pemahaman dilakukan menggunakan metode pre-test dan post-test. Hasil Kegiatan: Terjadi peningkatan pemahaman yang signifikan. Akurasi rata-rata kelas meningkat dari 91% menjadi 100%, disertai penurunan waktu pengerjaan rata-rata dari 2 menit 48 detik menjadi 1 menit 21 detik. Luaran kegiatan ini adalah publikasi artikel ilmiah pada jurnal terakreditasi dan peningkatan kompetensi mahasiswa dalam pengelolaan informasi klinis.. Kata Kunci: Manajemen Informasi Asuhan Keperawatan; Akurasi Diagnosis; Cedera Luar ABSTRACTSituation Analysis: Disease coding, particularly for external causes in emergency patient medical records, is essential but its accuracy is often challenged due to suboptimal completeness of nursing care documentation. This issue necessitates increasing the information management competency of Professional Nursing students, as they are future healthcare personnel. Objective: This community service program aimed to enhance the understanding of UNJAYA Professional Nursing students regarding the importance of nursing care information management in supporting the accuracy of external injury diagnoses. Implementation Method: The activity was carried out through training and counseling based on the transfer of knowledge and technology. Target Partner and Participants: The partner for this activity was 51 Professional Nursing students at UNJAYA. Evaluation of understanding improvement was conducted using pre-test and post-test methods. Activity Results: The program achieved a significant increase in understanding. The class-average accuracy improved from 91% to 100%, accompanied by a decrease in the average completion time from 2 minutes 48 seconds to 1 minute 21 seconds. The outputs of this activity are the publication of a scientific article in an accredited journal and a measurable increase in student competence in clinical information management.Keywords: Nursing Information Management; Diagnosis Accuracy; External Injury; Professional Nursing Students
Copyrights © 2025