Jumat, 15 Mei 2009

Efektivitas Organisasi, Kinerja perawat dan motivasi

Organizational Effectiveness
Effectiveness is a measure of success or achievement of a goal is achieved compared with what can be achieved. If the effectiveness based on the results, the achievement of human efforts on the possible results expressed in the form of output or quality. When reviewed the effectiveness of the means of achievement of achievement and develop what may be achieved when resources managed more effectively. Effectiveness also said the level of achievement as a goal or what was achieved in comparison with what may be achieved. If effectiveness is based on the results, the achievement of human effort toward a possible result is expressed in the form of output or quality. Effectiveness when viewed from the achievement of meaningful achievement cultivate workplace and what can be achieved if resources are managed more effectively. Further understanding of the effectiveness is the ability to choose the right destination or equipment suitable for the achievement of that goal has been set. Thus, an effective manager who can select the work to be done or the way to achieve this goal. Further understanding of the effectiveness is doing the right job (doing the right things), while efficiency is doing the work properly (doing thing right). For a manager, the most important question is not how to do the job properly, but how to find the right job to do, and focus resources and efforts on the job. For example a manager who insists to produce large cars, while market demand is aimed at small cars, which means that the manager is not effective even if the production cars are done with great efficiency. Effectiveness of the organization that is how far an organization to realize the goal-purpose. Alternatively it is said that the effectiveness of the organization is achieving the levels of short-term organizational goals. Further evaluation that reflects: konstituensi strategic interests and to evaluate the level of the organization to apply the criteria on the effectiveness of the organization as shown in table 1. Table 1. Organizational Effectiveness Criteria 1. Effectiveness of the overall 2. Productivity 3. Efficiency 4. Profit 5. Quality 6. Accident 7. Growth 8. Absenteeism 9. Employee turnover 10. Job satisfaction 11. Motivation 12. Moral / morale 13. Control 14. Conflict 15. Flexibility / adjustment 16. Planning and determination of 17. Consensus on goals 18. Internalization organizational goals 19. Interpersonal skills, managerial 20. Managerial skills 21. Information management and communication 22. Readiness 23. Power environment 24. External evaluation 25. Stability 26. Value of human resources 27. Participation funds which is used together with the influence 28. The emphasis on training and development 29. The emphasis on performance Organizations that must meet both conditions, among others, namely, (a) the purpose of the organization is clear and realistic, (b) the division of labor and the relationship between work units or sub-system parts must be well and clearly, (c) organization it must be a container of tools and effective in achieving goals, (d) the type of organization and structure must fit the needs of the company, (e) work units (department-departemennya) applied on the basis of eratnya employment relationship, (f) job description of each position must be clear and there is no overlapping work, (g) control every part of the range should be based on the volume of work and should not be too much, (h) of the command and responsibility must be clear, through the distance-the distance off, (i) the type of authority owned by each officer must be clear, (j) implementation of miss management employees are not available, (k) the relationship between the one with the other parts of the clear and harmonious, (l) delegation of authority should be based on the employee job description, (m) differentiation, coordination, the interaction and synchronization must be good, (n) organization must be flexible and elastic or (o) the organization must have a basic budget and household budget. Reverse of achievement goals, the system approach focuses on the ways necessary to ensure the viability of sustainable organizations. Must be observed also that the support system does not ignore the importance of the final goal as a certain determinan effectiveness of the organization. Instead, the leaders of the validity of the chosen destination and size that is used to assess progress towards these goals. With respect to the above, under this contention 4 the effectiveness of the model values can be seen in the picture below. Figure 1. Cost effectiveness model Source: Quoted from Stephen P. Robbins (2005) h. 79 The four models can be described as follows: (1.) Human relations model emphasizes the human and flexibility, the labor is integrated or cohesive and skilled as the destination. (2.) Open system model includes the flexibility and capability as a way to get the resources as a goal. (3.) Rational goal model, consisting of certain plans and objectives and as a means of productivity and efficiency as a high goal. (4.) Internal process model emphasizes the human element and the control and dissemination of information as a means of peace and stability as a goal in the assessment of effectiveness. While the organization is a system of cooperation activities carried out by two or more persons. Further that the organization can be defined as the collection of people with a system of cooperation to achieve shared goals. Senada with the organization that is any form of alliance between two or more persons who work for the same purpose and are bound together in a formal alliance. In this case there is always a relationship between / groups called a leader and / groups called a subordinate. Then according to Edgar H. Schein in Organizational Culture and Leadership defines the culture of general operations, but is: A pattern of shared basic assumption that the group learned as it salved its problems of external adaptation and internal integration, that has worked weal enough to be considered valid and, Reform the to be taught to new members as the correct way to perceive, think, and feel in relation, to these problems. While for the organization according to Robbins in Organizational Theory: Structure Design and Applications, cited by Ndraha is: Coordinate Aconsclausly social entity, with a relatively identifiable Boundary that function on a relatively continuous basis to achieve a common goal or set of goals. From the definitions explained that these organizations are: the social unity consciously coordinated, with a relatively sustainable limits to achieve common goals, or a series. Organization as a structure or order, especially in the preparation / placement of people in a group, or place also means that the relationship between those in the obligations, rights and responsibilities of each in the structure have been determined. According to another opinion, as quoted by Schein Muhammad said that the organization is a rational coordination of a number of people to achieve some common goal through the implementation of the division of functions and through the hierarchy of authority and responsibility. Further said that the organization is a particular characteristic, that is have a structure, goals, each associated with one of the other and rely on communication to coordinate human activities in the organization. Kochler then states that the organization is a system of structured relations that coordinate the efforts of a group of people to achieve a particular purpose. Meanwhile, Wright said that the organization is a form of open system of coordinated activities by two or more persons to achieve a goal together. In the book Human Resource Management written by Nawawi defines that the organization into two, namely the first is a static organization vessel rally because some people have the same interests. The second is the dynamic process of organization is the same amount of human work (two or more persons) to achieve this goal together. Other opinion explains that the organization is a system that consists of a pattern of cooperation activities conducted regularly and repeatedly by a group of people to achieve a goal. Understanding of the above shows that the organization has four elements, namely the system, activity patterns, a group of people and purposes. Based on the description above, the synthesis or function of the management unit of the activities undertaken by the organization relating to the duties and responsibilities as employees, among others, include planning, organizing, briefing, monitoring and evaluation. Employees in the duties and responsibilities of mengefektifkan always working to get a goal that may seoptimal. Organizational effectiveness is always the goal to empower the facilities and infrastructure that are appropriate for achieving the goals set. But the effectiveness of the organization referred to in this research is related to the indicators the effectiveness of the planning work, the effectiveness of the work, the effectiveness of communications and the effectiveness of personnel supervision and evaluation.

Work Discipline
The word discipline has a broad and frequently used in daily life, which indicates to an activity or action in accordance with the regulations. "The first word discipline comes from the Latin meaning disiplina training or education and the development of mold decency." Discipline is an important issue and needs to determine, and by the individual organizations that want to succeed in achieving the goal. A.S. Moenir revealed the importance of discipline in the following activities, discipline is one of the factors in the success of an activity. Please note that the success of a business is determined by three factors, namely: the seriousness, discipline and expertise. One of the factors does not have the results of operations will decrease both the quality and quantity. Therefore, the business mendisiplinkan employee must get the attention seriously. The Liang Gie explained, "Discipline is a situation where the order can be said of those who joined in an organization subject to regulation with happy." In this case, the discipline will be run well and smoothly when each member carrying a full awareness not because of the coercive elements of the leadership. Disciplinary work is basically an attitude shows that someone becomes a member of the organization. Attitude is the form of obedience to the rules and regulations that exist, such as raised IG Wursanto as follows, is a disciplined work style and way of life is orderly and organized by the dikhasiatkan self as kenampakan's awareness and confidence, identity and purpose and as kenampakan themselves against penghayatan and values that have be entrenched in the self. So it can be concluded that discipline is a work of obedience to rules, norms, standard, law, order that applies in the work environment, where someone subjugate themselves to work. Attitudes and behavior that is created through a process binaan through family, education and experience or knowledge of the pattern of the environment. Discipline will make himself know to distinguish the things that should be done, that must be done, which may be done, that should not be done (because the things forbidden). Discipline has three aspects, ie: 1. Mental attitude (mental attitude), which is an obedient and orderly manner as a result of training or development, control and mind control character. 2. A good understanding about the behavior of the system rules, norms, criteria and standards in such a way, so that understanding is the depth of understanding or awareness, that obedience akan rules, norms, criteria and standards before the absolute requirement for achieving success. 3. Attitude behavior that reasonably indicate the seriousness heart, to obey all things orderly and carefully. Discipline is born, grow and develop in a person's attitude in the cultural value system existing in the community. There are basic elements that make up the discipline, the first attitude that has been there himself on the human value system and culture in the community. Attitude or the attitude before the elements of life in the human soul to be able to react to their environment, can be a behavior or thought. While the cultural value system (Cultural value system) is part of the culture that serves as a guide or a guide or work for human behavior. Government Regulation Number 30 year 1980 is the discipline employees and is a Civil Affairs efforts in order to better enforce, improve the state apparatus and create a clean and authoritative, and sit down as a civil servant of the state apparatus must be a role model. Siswanto work revealed that the discipline as a gesture of respect, obsequious and obedient to the rules that apply whether written or not written, and able to run it and do not swerve to accept sanctions if they violate the duties and powers given to him. Disciplinary work is basically an attitude shows that someone becomes a member of the organization. Attitude is the form of obedience to the rules and regulations that exist, such as raised Atmosudirdjo that discipline is an attitude obedience to the institution or organization with what the requirements or without the use pemaksaan only keinsyafan based on that awareness and observance of such conditions is already of the goals of an organization and the company. On the other hand Wursanto support the opinion above, with the work said that discipline is a lifestyle and way of orderly and organized by the dikasiatkan self as kenampakan's awareness and confidence, identity and purpose and as kenampakan themselves against penghayatan and values of certain which has in itself be entrenched. So it can be concluded that discipline is a work of obedience to rules, norms, standard, law, order that applies in the work environment, where someone subjugate themselves to work. In order to regenerate and develop the discipline required of a member of the organization, such as that raised by Moenir, "that in the case of discipline of any object there are three factors that work and the discipline is to maintain awareness, pattern, setting the observance." Awareness factor here is the main factor, while the pattern and tightness factor is a broadcaster and brace against the main factor. Pattern and the settings will not be able to survive without awareness based by, otherwise if there is awareness of the pattern and tightness settings akan attitude strengthen discipline someone. Someone or something the group can be forced to discipline but is a better discipline arising from the awareness, understanding and keinsyafan good about the goals and loyal to superiors. However, keep in mind that the awareness of the discipline that does not appear as such, all that needs to be done of the discipline. Many factors affect the development of the discipline. Martoyo revealed the factors that influence the development disciplines are 1) motivation, 2) welfare, 3) leadership, 4) education and training, and 5) the law enforcement discipline. Disciplinary punishment is a punishment because it violates the rules be disciplined. Disciplinary punishment which should be in kind with a breach of discipline is made, so that the disciplinary penalties that may be accepted by justice. Some approaches to the discipline of: a. The approach traditionally b. Oriented approach that targets the workplace a. Traditional Approach 1. Discipline is, as always there will be a tendency on the employee to violate the restrictions-restrictions. Because the discipline is an effort to prevent and actions prohibited. Because discipline is punishment should balance with the weight violations. 2. Heavy sentence must be able to have the effect of fear for those who have not been violated in order for that trend can be stopped or prevented. 3. In the penalty must be maintained to provide keadilannya means that the punishment must be subjective and not always consistent. 4. Heavy penalties for breaches of the past should always be punished more heavily than before. b. Oriented approach that targets the workplace This approach is to see that the rules and restrictions-only restrictions are restrictions that can be determined and ensure achievement of targets. This approach holds that: 1. Discipline is a means that is needed in order to direct behavior. Discipline is not the law. 2. Disciplinary work that is defined and should be seen as something that must be accepted by employees to volunteer as a guide. 3. Efforts towards achieving the goals is important if compared with the offense. 4. Therefore, the regulations and have received must always be reviewed if still support the achievement of goals or have hindered the achievement of the goal. Example of restrictions and obligations of Pegawai Negeri Sipil RI is: a. Civil Affairs Officers Liability 1. Fully faithful and loyal to the Pancasila, Undang-undang Dasar 1945, and the State Government. 2. Interests of the country above the interests of groups or self. 3. Respect the honor and dignity of the country, the government and the Civil Affairs Officers. 4. And obey the oath / promise Employees and Civil Affairs office. 5. Save a secret country / office. b. Restrictions for the Civil Affairs Officers 1. Doing things that can decrease the honor or dignity of the state, government or the Civil Affairs Officers. 2. Misuse the authority. 3. Become civil servants or work for a foreign country without government permission. 4. Misuse goods, money or securities belonging to the state and beyond. 5. Having a company that shares its business activities is not in the scope of authority of the amount and nature of ownership is such that the ownership shares can be directly or indirectly determine the way a company or organization. Level and Type of Legal Discipline Common law there are 3 levels of discipline, namely: a. Light level legal discipline b. Level of legal disciplines are c. High-level legal discipline Three levels of law and each level has a type of law that are graded. ad. a. Type of legal discipline is light: 1. Verbal reprimand from the boss 2. Written reprimand 3. The statement is not satisfied in writing ad. b. Type of punishment is a discipline are: 1. Delay periodic salary increases for most one year old 2. The biggest decrease in wages or salary increase in time for the regular one year old. 3. Delay promotion to a maximum of one year ad. c. Type of disciplinary penalty weight is: 1. Demotion to lower at most one year old 2. Exemption from the office 3. Dismissal with respect at the request does not own 4. Dismissal is not with respect Measures of Discipline The conditions that need to be prepared so that work can be achieved disciplines, including: 1. All employees should be clear that there are rules and responsibilities within the organization. Regulation itself must be clear and of each other. 2. Cegahlah early as possible behavior that can cause violations more or do not create opportunities for it. 3. Apply the procedures of discipline consistently. 4. Listen and consider carefully what the people and what diresahkan. 5. Bedakanlah explicit violations are included mild, moderate or heavy. 6. Once someone has finished a disciplinary punishment, such as temporary work stoppage, the employee must be treated like other employees, we do not pursue the error. 7. Do not trap people to violate the discipline because it will cause a desire to violate the rules and does not educate. The goal of discipline is to prepare the order in which ditegakkan and taking disciplinary action against the firm that does not obey the discipline. In order to achieve the goal that needs to: 1. Clarity of rules and strictly with sanctions. 2. Expectations of what can be taken from each employee. 3. Understanding the size-measure in the works. 4. Investigation thoroughly and objectively, that if violations occur. 5. Disciplinary action the firm. Pattern disciplinary action, including reprimand, warning, removal, a statement is not skilled work, suspension, demotion and dismissal. Implementation of the discipline of employees is expected to be the feeling that as the executive has an important role, because they realize that this is a key to success in the discharge of duties and responsibilities of each, so encourage every employee to strive to understand the subtlety field work as part of involved determining the success of a company or a company's productivity. Awareness will develop a positive attitude discipline perwujudannya a willingness to participate maximally in carrying the burden of working together with other employees. Discipline is a positive discipline that konstrukif, so that is a good habit, a reaction against the values and norms that apply in the community. Discipline is positive this can be realized in an organization when there is the atmosphere that allows employees to adjust with the actual situation. Discipline is good not only directed to conviction or with the provisions of the rigid, because the compulsion to take the pressure and punishment. But allows the employees in an organization the freedom to enjoy both the freedom to issue opinions, to participate in a maximum, and berimprovisasi in the production process to achieve the goal. This will make employees feel that the goals and interests as the interests of the organization itself. To find out the employee discipline, discipline Lateiner revealed that there are sincere when employees come in the office with a regular and timely, well-dressed well when on the job, when using the equipment and materials carefully, following the way to work when work is specified office or company, when completed the job with a good spirit. Thus it can be concluded that the discipline of a nurse is a nurse that attitude and adhere to the abiding norms and rules set in the job. Next to the discipline of nurses used indicators 1) attendance, 2) order, 3) the procedures work, and 4) responsibility.

Work motivation
Motivation can be defined as a process of overall guidance and encouragement to the work of the subordinate so that they would work well, to achieve the goals of the organization. Edwin B. Flippo explained "In the words of motivation sometimes being confused with the term motif, motivation and work incentif". In fact all that different. The Arifin Abdul Rachman argued that the motivation is to make the management of other people like to be able to work and the management must be able to or should have the art of others. While in theory, administration and management according to Sondang P. Siagian divided between the administration and administrative motivation. Motivating be comprehensive and all the people in the organization particularly in terms of determining policy. Managerial while motivating is a special and more weight to the motives of the operation only. When more of the three concepts considered opinion of experts can be drawn conclusions as follows: a. Motivation is all the impetus that complement the existing alasan-alasan/dorongan-dorongan in human to move, we understand the first oddity lakunya. b. Motivation is to make the management of other people love and want to work with both. c. Role of motivation is a series of activities that the organization views from some of the elements above that sometimes the motivation in the closely related human relationship with the organization. While H. Malayu SP Hasibuan, revealed that the "Motivation discuss how to direct resources and potential subordinate, so that would work in productive, achieve a goal that has been determined." George R. Terry, further explained that "Motivation is the desire and the desire that is in someone who stimulates him to action." From the above conclusions can be drawn that the motivation or encouragement from the leaders of the subordinate executive to work with and provided support so that human behavior enterprising, enthusiastic, achieve optimal results with a high benefit. Peterson and Plowman as quoted by Hasibuan revealed that people want to work because: a. The desire to live (the desire to live) b. The desire for position (the desire for a position) c. The desire for power (the desire for power) d. The desire for recognition (recognition of the desire akan). The need for employees to live a physical office covers the needs and security, social and self-satisfaction. Physical and security needs such as clothing, food and board (housing). While the social needs related to the status, recognition, honor in the social crowd. While the self-satisfaction associated with the ego of each person. Many of the goals be achieved in motivating employees or subordinate to, among other moral guidance for employment, productivity, employee stability, work discipline, the relationship of cooperation, loyalty, creativity and welfare work. In-principle basis to motivate subordinate leaders by covering fundamental satisfaction and increased work productivity. H. Malayu SP-Hasibuan explain fundamental principle is to improve the efficiency and effectiveness of work as "the principle of participation, the principle of communication, recognition of the principle, fundamental principle of authority and equal attention back." Theoretical basis of the above, the process of motivation can be as follows: 1. There is a need that has not been met 2. Find a way to meet the needs 3. Behavior-oriented goals 4 Results in the paper work 5. Rewards and punishment to instill discipline 6. Improvements if there is an error and needs fulfillment. Development of role motivation is very important, although difficult to achieve. This is because things like below. 1. Factors that encourage someone to enthuse work. 2. Differences in views of each person in the work always different, while the job demands the best results. 3. Equipment or instruments in encouraging people to work differently and not always uniform. The role of motivation in an office is the responsibility of leaders of institutions, not the office staff. This is the decision of management in encouraging employees to work or is a structural leadership, not staff. Based on the description above, the motivation of the nurse is encouraged to rise to the desire to do the activity or event in the running task as a nurse who carried out systematically, repeatedly, continuously and progressively to achieve the goal. As for which the indicator is awareness, needs, expectations, praise, punishment and rules. 2.2. The framework 2.2.1. The influence of the Discipline of Nurses Organization Effectiveness Disciplinary work is organized and orderly condition of the nurse in performing duties and subject to the regulations that apply to the happy and full awareness. The situation can be seen from the constancy of the order, the implementation of appropriate procedures or guidelines, with hours of work and responsibility in performing a given task. Achievement of a high, if a nurse is able to carry out the tasks given to her leadership. To be able to do the tasks given, nurses are required to have the discipline of working with high level of discipline because of the high, the nurses will have the responsibility of the duties and responsibilities. Nurses who have a high work discipline, will come on time, the tasks completed on time and home work in accordance with existing rules. These things will lead to a nurse working with the spirit so that full achievement of the diraihnyapun akan high and ultimately the effectiveness of its organization will be high also. The higher the discipline of nurses expected the higher the effectiveness of the organization will be achieved. Thus there is a suspected positive influence on the discipline of organizational effectiveness of a nurse. In other words, the higher the discipline of a nurse, the higher the effectiveness of the organization. Similarly, the lower the discipline of the workplace by a nurse, the lower the effectiveness of the organization.

Rabu, 13 Mei 2009

Perawat dan dokumentasi asuhan keperawatan


Perawat adalah orang yang mengasuh , merawat dan melindung orang sakit, luka dan lanjut usia (Ellis dan Hertley,1980 : Robert, 1995 ). Sedangkan Virginia Henderson (1985 ) mengatakan fungsi unik dari perawat adalah membantu idividu yang sehat dan yang sakit dalam melaksanakan segala aktivitasnya untuk mencapai kesehatan dan kesembuhan atau untuk meninggal dunia dengan tenang yang dapat ia lakukan sendiri tanpa bantuan apabila cukup kekuatan, harapan dan pengetahuan. Perawat juga berfungsi membantu hal-hal ini dalam upaya mencapai kemandirian secepat mungkin ( Person dan Voughan, 1986).
Menurut Lokakarya Keperawatan Nasional (1983) definisi keperawatan adalah suatu bentuk pelayanan professional yang merupakan bagian integral dari pelayanan kesehatan yang didasarkan pada ilmu dan kiat keperawatan, bentuk pelayanan bio, psiko, sosio dan spiritual yang komprehensif serta ditujukan kepada idividu, keluarga dan masyarakat baik sehat maupun sakit yang mencakup seluruh siklus kehidupan manusia.

2. Dokumentasi Asuhan Keperawatan
Keperawatan dan catatan tentang respon pasien terhadap tindakan medis, tindakan keperawatan atau reaksi pasien terhadap penyakit (Depkes RI 1994). Dokumentasi keperawatan adalah suatu upaya penyusunan catatan atau dokumen yang berisi keterangan tentang riwayat kesehatan pasien, status kesehatan pasien saat ini, perawatan yang diperlukan dan perwatan yang telah diberikan (Fisbach, 1991 : 11).
Berdasarkan beberapa pengertian diatas dapat disimpulkan bahwa dokumentasi asuhan keperawatan adalah suatu pencatatan yang dilakukan perawat berisi tentang riwayat kesehatan pasien status kesehatan pasien saat ini, perawatan yang diperlukan, perawatan yang diberikan serta respon terhadap tindakan keperawatan yang diberikan.

I. Tujuan dan Kegunaan Dokumentasi Asuhan Keperawatan
Berdasarkan Depkes RI (1994) dokumentasi mempunyai beberapa tujuan yaitu sebagai berikut :
a. Sebagai sarana komunikasi
Catatan mengenai status kesehatan pasien pada dokumentasi asuhan keperawatan merupakan suatu cara bagi perawat untuk berkomunikasi melalui tulisan. Catatan keperawatan perlu bersifat permanen sesuai dengan kondisi pasien. Catatan yang teliti dan lengkap akan berguna untuk :
(1) Membantu koordinasi asuhan keperawatan yang diberikan oleh tim kesehatan.
(2) Mencegah informasi yang berulang-ulang kepada pasien oleh anggota tim kesehatan .
(3) Mebantu perawat menggunakan waktu yang sebaik-baiknya karena mencegah tumpang tindih.

b. Sebagai mekanisme pertanggungjawaban dan pertanggunggugatan
c. Sebagai metode pengumpulan data
d. Sebagai sarana pelayanan perawatan secara individual dengan mengintegrasikan berbagai aspek yaitu bio, psiko, sosial spritual guna menggali kebutuhan, kekuatan dan keadaan khusus pasien. Hal ini berguna untuk menentukan intervensi keperawatan yang akan menjamin dan terarahnya asuhan keperawatan.

II. Prinsip-Prinsip Dokumentasi Asuhan Keperawatan
Berdasarkan Carventio (1995: 10) hal-hal dalam prinsip dokumentasi adalah :
1) Dokumentasi asuhan keperawatan harus dilaksanakan segera setelah pengkajian pertama dilakukan, demikian juga pada setiap langkah kegiatan perawatan.
2) Bila memungkinkan, catat setiap data yang dicatat dalam dokumentasi asuhan keperawatan.
3) Pastikan kebenaran setiap data yang dicatat dalam dokumentasi asuhan keperawatan .
4) Data pasien harus objektif dan bukan hasil penafsiran perawat, dalam hal ini perawat mencatat apa yang dilihat dan respon pasien pada saat merawat pasien mulai dari pengkajian sampai evaluasi.
5) Dokumentasi asuhan keperawatan dengan apabila terjadi hal-hal seperti adanya perubahan kondisi atau munculnya masalah baru respon pasien terhadap bimbingan perawat.
6) Penulisan istilah yang tidak jelas dari setiap catatan yang di buat harus dihindari, istilah yang digunakan harus dapat disepakati atas kebijakan institusi setempat.
7) Dokumentasi yang baku harus dihindari, sebab sifat individu atau pasien adalah unik, selain setiap pasien mempunyai respon yang berbeda.
8) Data harus ditulis dengan jelas menggunakan tinta dan jangan menggunakan pensil agar tidak mudah dihapus. Tidak dibenarkan untuk mengubah isi dokumen untuk menutupi kesalahan
9) Apabila terjadi kesalahan dalam penulisan dapat dicoret dan segera diganti dengan yang benar, kemudian ditandatangani.
10) Untuk setiap kegiatan dokumentasi, cantumkan waktu , tanda tangan dan nama jelas yang melaksanakan dokumentasi
11) Wajib membaca setiap tulisan dari tim kesehatan yang lain sebelum menulis data terakhir
12) Dokumentasi harus dibuat dengan jelas dan lengkap.

III. Teknik Pencatatan Dokumentasi Asuhan Keperawatan Meliputi :
a. Pencatatan Dengan Naratif
Bentuk narasi merupakan sistem pencatatan yang berbentuk cerita atau kalimat. Pencatatan ini memperhatikan unsur siapa yang mencatat, mengapa harus dicatat, dan kapan informasi/data tersebut didokumentasikan. Keuntungan pencatatan secara naratif adalah :
1) Meningkatkan pencataan secara kronologis yang akan membantu interpretasi rangkaian kejadian yang dialami pasien.
2) Catatan dengan evaluasi pertanyaan waktu yang spesifik saat pasien masuk, dipindahkan, perubahan kondisi pasien

b. Pencatatan Dalam flow Sheet dan Check List
Flow Sheet dan Check List memperlihatkan perkembangan pasien actual, dirancang untuk memperoleh informasi pasien yang spesifik menurut parameter yang telah ditentukan sebelumnya. Flow Sheet sering disebut dengan catatan perkembangan ringkas contoh pencatatan dengan flow sheet dan check list : (1) ADL, tanda-tanda vital, keseimbangan cairan (intake out put), (2) Nutrisi, pengkajian kulit review system tubuh, (3) Hasil laboratorium.
Keuntungan flow sheet dan check list; (1) Meningkatkan kualitas observasi pada pendokumentasian. (2) Mudah dibaca, (3) Dokumentai keperawatan lebih cepat, (4) Meningkatkan penyediaan data pasien dapat diperoleh dengan cepat, (5) Perbandingan data dapat ditingkatkan dari beberapa periode, (6) Pencatatan informasi tepat, relevansinya dapat dipertanggungjawabkan secara hukum dan sangat berguna.
Kerugian flow sheet dan check list adalah : (1) Medical record lebih luas dan masalah keperawatan tidak kelihatan, (2) Potensi terjadi duplikasi atau pengulangan pencatatan, (3) Kolom yang kosong dan sempit untuk catatan yang komprehensif biasanya tidak cukup. Petunjuk pengisian flow sheet dan check list adalah sebagai berikut:
(1) Lengkapi format dan gunakan kode-kode yang ditetapakan : Gunakan check (V) atau silang (X) atau lingkaran (O), beri tambahan-tambahan data yang dibutuhkan secara teliti sesuai kebutuhan.
(2) Letakan kolom flow sheet dan check list dalam kondisi yang tepat pada tempat yang sudah disediakan sehingga perawat dapat memasukan data tentang kondisi pasien secara tepat.
(3) Sediakan tempat untuk tanda tangan perawat.
(4) Dokumentasi waktu pemasukan data
(5) Dokumentasi tanggal pemasukan data

IV. Tahap-Tahap Pendokumentasian Asuhan Keperawatan
2.5.1. Dokumentasi Pengkajian Asuhan Keperawatan
Effendy (1995) mengatakan bahwa “Pengkajian merupakan tahap awal proses keperawatan dimana informasi yang terkumpul dari pasien digunakan untuk menentukan diagnosa keperawatan, merencanakan asuhan keperawatan, serta tindakan keperawatan untuk mengatasi masalah”. Pengkajian keperawatan merupakan gambaran terhadap fase pengumpulan data dari proses keperawatan yang membutuhkan data yang terkumpulkan dan sistematik (Fischbach, 1991 : 125), Pengkajian adalah tahap awal dari proses keperawatan yang merupakan tahap pengumpulan data.
Data dikumpulkan dan diorganisir secara sistematis, serta dianalisa untuk menentukan masalah keperawatan pasien. Data pada pengkajian diperoleh melalui wawancara, pemeriksaan fisik, pemeriksaan laboratorium maupun pemeriksaan diagnostik yang lain. Perawat harus mencatat semua pengkajian keperawatan secara sistematis, akurat dan komperatif. Tujuan Pendokumentasian Pengkajian Asuhan Keperawatan. Tujuan dari pengkajian itu sendiri adalah utnuk mengumpulkan data merekam data yang dapat menggambarkan respon manusia terhadap masalah kesehatan (Fishcbach, 1991 : 125). Tujuan dari pendokumentasian asuhan keperawatan adalah :
(1) Untuk mengidentifikasi kebutuhan pasien dan responnya terhadap masalah kesehatan.
(2) Untuk mengelompokan dan mengorganisir informasi yang diperlukan sehingga pola kesehatan pasien dapat dianalisa dan masalah dapat diidentifikasi.
(3) Untuk mengidentifikasi karakter yang khas dari kondisi pasien dan responnya yang dapat mempengaruhi perencanaan dan tindakan serta cara pemberian pelayanan keperawatan
(4) Untuk memastikan adanya informasi dasar yang berguna untuk memberikan referensi dalam mengukur perubahan kondisi pasien.
(5) Untuk mengumpulkan data yang memberikan dasar bagi pencatatan rencana keperawatan.
(6) Untuk memberikan dasar bagi pencatatan rencana keperawatan selanjutnya yang efektif.

V. Diagnosa Keperawatan
Teung (1994) mendefinisikan diagnosa keperawatan sebagai perumusan masalah kesehatan yang aktual atau potensial dari individu, keluarga atau kelompok dimana perawat dapat secara legal membantu secara independen atau mandiri. Dalam melakukan diagnosis, perawat harus mengacu pada rumusan yang telah ditetapkan. Rumusan diagnosa keperawatan adalah sebagai berikut: 1). Diagnosa keperawatan yang bersisfat nyata (aktual) yang tersusun atas Problem, etiologi, symtomp; 2). Diagnosa keperawatan yang bersipat potensial dirumuskan sesuai dengan masalah yang mungkin timbul berdasarkan kondisi yang pasien hadapi sekarang. (Gordon,1997).

VI. Perencanaan Keperawatan.
Teung (1994) menyatakan bahwa tahap ini meliputi menentukan prioritas masalah, menentukan dan menetapkan hasil yang akan dicapai atau tujuan asuhan keperawatan, menentukan rencana tindakan keperawtan atau intervensi, dan menentukan hasil yang akan dicapai. Dalam Menentukan prioritas masalah perlu dipertimbangkan masalah yang mengancam kehidupan, masalah yang mengancam kesehatan dan masalah yang menyangkut kesenangan pasien. (Kozier, 1995).
Perumusan tujuan pada perencanaan keperawatan adalah untuk mengarahkan asuhan keperawatan yang diberikan kepada pasien agar hasil yang diinginkan tercapai dan masalah yang tengah dihadapi pasien dihilangkan atau dikurangi. Pernyataan tujuan harus ada subyek, predikat dan kriteria. Subyek yaitu pasien atau bagian dari pasien, predikat adalah kegiatan atau aksi dari pasien, sedangkan kriteria adalah spesipik. Measurable, Achievable, Realistic dan Time limited. (Capernito, 1999).
Dalam perencanaan keperawatan juga ditetapakan kriteria hasil yang akan dicapai. Kriteria hasil adalah pernyataan yang menggambarkan perilaku pasien atau keluarga dapat diukur dengan menunjukan status yang lebih baik setelah pemberian asuhan keperawatan. (Capernito,1999)

VII. Implementasi atau Intervensi Keperawatan
Teung (1994) mendefinisikan implementasi keperawatan adalah pelaksanaan atau penerapan tindakan-tindakan yang telah direncanakan. Sedangkan menurut Nattina (1996), implementasi keperawatan adalah kegiatan mengkoordinasikan aktivitas pasien, keluarga, anggota tim kesehatan lain, mengawasi dan mencatat respon pasien terhadap tindakan keperawatan yang telah dilakukan.

VIII. Evaluasi Keperawatan
Menurut Cristensen dan Kenny (1995), evaluasi keperawatan adalah kegiatan yang terdiri dari : a). Membandingkan respon pasien dengan tujuan yang telah ditetapkan. b). Menggunakan kriteria standar untuk evaluasi yaitu Subyektive, Objective, Achiavement dan planning,
c). Menentukan tingkat kemajuan pasien. d). Merevisi rencana keperawatan.

Faktor-Faktor yang Melatarbelakangi pendokumentasian Asuhan keperawatan
1. Faktor pendorong atau Predisposisi : Pengetahuan dan sikap
a. Pengetahuan
Pengetahuan adalah merupakan hasil dari tahu, dan ini terjadi setelah orang melakukan pengindraan terhadap sesuatu obyek tertentu. Pengindraan terjadi melalui panca indra manusia yakni indra penglihatan, pendengaran, penciuman, rasa dan raba. Sebagian pengetahuan manusia diperoleh melalui mata dan telinga. (Notoatmojo, 1993 : 94)
Pengetahuan merupakan domain yang sangat penting utnuk terbentuknya tindakan seseorang dari pengetahuan akan lebih langgeng (Long Lasting) daripada perilaku yang tidak didasari oleh pengetahuan (Notoatmojo, 1993 :94). Pengetahuan perawat dalam penelitian ini meliputi 6 (enam) tingkatan semakian ke atas tingkatan pengetahuan perawat semakin baik pengaruhnya terhadap perilaku. Tingkatan itu adalah :
(1) Mengetahui, diartikan sebagai kemampuan perawat untuk mengikatkan materi berkaitan dengan dokumetasi asuhan keperawatan yang telah didapat sebelumnya melalui pendidikan keperawatan dan pelatihan. Sebagai contoh perawat dapat menyebutkan pengertian dokumentasi asuhan keperawatan.
(2) Memahami, diartikan sebagai kemampuan perawat untuk menjelaskan, menyebutkan contoh dapat menjelaskan mengapa perawat harus melakukan dokumentasi asuhan keperawatan.
(3) Aplikasi, diartikan sebagai kemampuan perawat untuk menggunakan materi tentang dokumentasi asuhan keperawatan diberbagai tatanan pelayanan kesehatan, seperti di rumah sakit, perawat harus mampu menggunakan metode asuhan keperawatan sebagai pemecahan masalah dalam memberikan pelayanan.
(4) Analisis, adalah kemampuan perawat untuk menjabarkan dokumentasi asuhan keperawatan ke dalam komponen, tetapi didalam satu lingkup dan masih ada kaitannya satu sama lain. Kemampuan analitik ini dapat dilihat dari penggunaan kata kerja, seperti dapat membedakan, mengelompokan misalnya, perawat mampu mengelompokan data hasil pengkajian.
(5) Sintesa, dapat diartikan dengan kemampuan perawat meletakan atau menghubungkan bagian-bagian dari asuhan keperawatan didalam suatu diagnosa dari hasil pengkajian dan analisanya serta dapat merencanakan tindakannya.
(6) Evaluasi, hal ini dikaitkan dengan kemampuan perawat untuk melakuan justifikasi atau penilaian terhadap dokumentasi suatu criteria yang ditentukan sendiri atau menggunakan criteria yang sudah ada.

Penelitian Rogers (1974) dalam Notoatmojo (1993:92) mengungkapkan bahwa sebelum orang mengadopsi perilaku baru didalam diri orang tersebut terjadi proses yang berurutan, yakni : Awerness (kesadaran). Dimana orang tersebut menyadari dalam arti mengetahui terlebih dahulu terhadap stimulus, dalam hal ini stimulusnya adalah dokumentasi asuhan keperawatan. Interest, dimana orang mulai tertarik pada stimulus (dokumentasi asuhan keperawatan), evaluasi, yakni menimbang-nimbang terhadap baik tidaknya stimulus terhadap dirinya. Trial, dimana orang mulai mencoba perilaku baru dan adopsi dimana orang telah berperilaku baru sesuai dengan pengetahuan, kesadaran dan sikapnya terhadap stimulus.
Apabila adopsi perilaku melalui proses seperti ini, dimana disadari oleh pengetahuan kesadaran dan sikap yang positip, maka perilaku tersebut akan bersipat langgeng. Pengetahuan perawat tentang dokumentasi asuhan keperawatan dapat dipengaruhi oleh pengetahuan, pengalaman, sikap dan keyakinan. Pengetahuan yang benar tentang dokumentasi asuhan keperawatan akan membuat perawat lebih mudah melaksanakan pendokumentasian.

b. Sikap (Attitude)
Sikap merupakan reaksi atau respon yang masih tertutup dari seseorang terhadap suatu stimulus atau obyek (Notoatmojo, 1993 :97). Sikap diartikan juga sebagai bentuk evaluasi atau reaksi perasaan terhadap suatu obyek memihak atau tidak memihak yang merupakan keteraturan tertentu dalan hal perasaan (afeksi), pikiran (kognisi) dan predisposisi tindakan (konasi) terhadap suatu obyek di lingkungan sekitar.
Newcomb dalam Notoatmojo (1993 : 97) mengatakan bahwa sikap ini merupakan kesiapan atau kesediaan untuk bertindak dan bukan pelaksanaan motif tertentu. Seperti halnya pengetahuan, sikap juga mempunyai beberapa tingkatan yang bersifat hirarki dengan pengenalan sebagai tingkatan yang paling sederhana dan pengalaman sebagai tingkat yang paling tinggi.
(1) Pengenalan, pada tahap ini seseorang baru mengenal, bersedia menerima dan memperhatikan berbagai stimulus. Misalnya perawat bersedia menghadiri seminar tentang dokumentasi asuhan keperawatan.
(2) Pemberian respon, pada tahap ini seseorang diharapkan untuk menunjukan perilaku yang diminati, misalnya berpartisipasi atau memberikan tanggapan secara sukarela bila diminta. Sebagai contoh perawat bersedia ikut berpartisipasi dalam rangka pelaksanaan dokumentasi asuhan keperawatan.
(3) Penghargaan terhadap nilai, pada tahap ini seseorag perawat konsisten berperilaku sesuai dengan sesuatu nilai meskipun tidak ada fihak yang meminta atau mengharuskan. Sebagai contoh perawat yakin bahwa dokumentasi asuhan keperawatan harus dilaksanakan.
(4) Pengorganisasian, pada tahap ini seseorang menjadi commited terhadap sesuatu nilai dan diharapkan untuk mengorganisasikan berbagai nilai yang dipilihnya kedalam suatu sistem nilai dan menentukan hubungan antara nila-nilai tersebut. Sebagai contoh seorang perawat memutuskan untuk membuat dokumentasi asuhan keperawatan demi kewajiban bukan demi nilai kredit, kenaikan pangkat atau akreditasi rumah sakit.
(5) Pengalaman, pada tahap ini seseorang bukan saja telah mengintegrasikan nilai-nilai tersebut kedalam suatu filsafat hidup yang lengkap dan meyakinkan serta perilakunya selalu konsisten dengan filsafat hidup tersebut. Sebagai contoh seorang perawat yang berpandangan bahwa dokumentasi asuhan keperawatan adalah penting dan merupakan kewajiban seorang perawat, maka walaupun banyak tugas lain ia akan tetap melakukan pendokumentasian.

Sikap seseorang yang positif belum tentu terwujud dalam tindakan positif, begitu pula sebaliknya. Temuan-temuan dari penelitian lain menyebutkan bahwa hubungannya adalah positif. (Azwar, 2002 :16). Menurut Brecter dan Waggins yang dikutip Azwar (2002:16) bahwa sikap seseorang akan berpengaruh langsung terhadap perilaku sangat tergantung pada kondisi apa, waktu bagaimana dan situasi bagaimana, karena berdasarkan pengetahuan dan sikap, perawat akan dapat melaksanakan dokumetasi asuhan keperawatan dengan baik dan sungguh-sungguh.

2. Faktor Penguat atau Reinforcing Factor
Fasilitas dan sarana adalah sesuatu yang dapat dipakai sebagai alat yang dipakai mencapai maksud dan tujuan (Kamus Besar Bahasa Indonesia, 2002: 999). Faktor sarana berhubungan dengan tersedianya format pendokumentasian, petunjuk atau pedoman pendokumentasian dan tempat atau ruang yang refresentattif (Fishbach, 1991). Dalam hal ini sarana untuk memudahkan pelaksanan dokumentasi asuhan keperawatan yang paling utama adalah format asuhan keperawatan. Sarana yang tersedia mutlak perlu dimanfaatkan sedemikian rupa sehingga manfaat yang sebesar-besarnya dipetik dari padanya (Siagian, 1997: 151).

3. Faktor Pemungkin atau Enabling Factor
a. Faktor Manajemen atau Supervisi
Supervisi merupakan salah satu fungsi yang harus dilakukan oleh pimpinan dalam rangka membantu bawahannya dalam melaksanakan tugas untuk pencapaian tujuan dan standar organisasi.Pimpinan di lini pertama untuk sebuah organisasi pelayanan perawatan (first line manager) adalah kepala ruangan. Sedangkan pemimpin yang lebih atas ialah kepala bidang keperawatan, pemimpin di setiap hirarki mempunyai tugas mengawasi dan mengkoordinasikan tugas-tugas bawahannya dalam melaksanakan tugas-tugas untuk pencapaian tujuan dan standar organisasi. (Eachhern, 1969 :115)
Supervisi sebaiknya tidak terbatas, karena akan memudahkan proses pengawasan terhadap pekerjaan yang sedang berlangsung sehingga dapat mengetahui apabila ada kesalahan serta memperbaiki pelaksanaan dokumentasi asuhan keperawatan. Penelitian menunjukan bahwa pelaku seorang supervisi yang baik akan dapat memberikan kepuasan bawahannya.

b. Faktor Kebijakan
Kebijakan adalah rangkaian konsep yang menjadi garis besar dan rencana dalam pelaksanaan suatu pekerjaan dan cara bertindak (Kamus Besar Bahasa Indonesia, 2002:149). Menurut Gilies (1994 :697) Poliy atau kebijakan merupakan pernyataan sasaran jangka panjang organisasi. Misalnya suatu kebijakan rumah sakit berbunyi bahwa semua perawat harus melaksanakan dokumentasi asuhan keperawatan.
Kebijakan menerangkan bagaimana tujuan dapat dicapai dan sebagai penuntun dalam mendifinisikan arah dan lingkup pencapaian tujuan tersebut (Tomey, 1992 : 144). Oleh karena itu kebijakan harus melibatkan semua perawat yang akan terkena kebijakan tersebut, harus konsisten dan membantu dalam memecahkan atau mencegah masalah spesifik.