Utilization of the SIMPACA Application to improve the quality of nursing care documentation for nurses

Abstract

The phenomenon of nurses in hospitals being preoccupied with recording documentation activities manually compared to providing independent nursing care to patients. One of the reasons for improving the behavior of nurses in documenting nursing care is increasing the ability of nurses to do documentation using application assistance to facilitate the work of nurses. This community service activity aims to improve the ability of nurses to document effectively and efficiently. The activity was carried out for two days through a zoom meeting. Previously, at the beginning of the activity, a nurse's ability pre-test was conducted and at the end of the session, another measurement was made for the nurse's ability. Community service activities were carried out with 45 nurses in South Sumatra. During the activity, the participants were very enthusiastic in listening, discussing with resource persons, and doing simulations well. There is an increase in documentation ability before and after the documentation training using SIMPACA is carried out. SIMPACA is proven to be effective in improving nurses' documentation skills and reducing nurses' time in documenting their nursing care to patients. There is a need for further development of SIMPACA because it must adapt to the needs of the hospital.

Factors Related to Nurses' Motivation in Carrying Out Nursing Documentation in the Surgical and Internal Rooms at Kudungga Sangatta Regional Hospital

“…Permasalahan yang sering ditemui dalam setting terkait pendokumentasian di Indonesia adalah pendokumentasian yang tidak sesuai format, seperti kurang akuratnya proses keperawatan yang terjadi pada tahap diagnosis keperawatan (50,5%) dan tahap perencanaan keperawatan (48,4%) . Diagnosis tidak didasarkan pada masalah, etiologi, atau gejala (89,6%); Diagnosis aktual/potensial tidak dikembangkan (51%); Rencana tidak disusun berdasarkan prioritas (95,3%); tidak mencakup tujuan yang diharapkan (93,4%), dan masih ragu-ragu dalam menentukan diagnosa keperawatan yang tepat karena kurangnya pengalaman (Natosba, 2022).…”