The Hubungan Literasi Digital Dan Supervisi Kepala Ruangan Dengan Kesesuaian Dokumentasi Asuhan Keperawatan Berbasis Electronic Medical Record Di Ruang Rawat Inap Rumah Sakit Dr. Hafiz Cianjur

Relationship Between Digital Literacy and Ward Head Supervision With The Suitability of Electronic Medical Record-Based Nursing Care Documentation in the Inpatient Ward Of Dr. Hafiz Cianjur Hospital

Abstract

Abstrak

Pendahuluan: Dokumentasi asuhan keperawatan merupakan bagian penting dari rekam medis. Di era digital saat ini, dokumentasi asuhan keperawatan telah beralih ke rekam medis elektronik (Electronic Medical Record) yang menuntut pengisian data secara lengkap, sistematis, dan sesuai standar, sehingga literasi digital perawat serta supervisi kepala ruangan berperan penting dalam memastikan kesesuaian dokumentasi asuhan keperawatan di ruang rawat inap. Tujuan: Tujuan penelitian ini untuk mengetahui hubungan literasi digital dan supervisi kepala ruangan dengan kesesuaian dokumentasi asuhan keperawatan berbasis electronic medical record di ruang rawat inap Rumah Sakit Dr. Hafiz Cianjur. Metode: Penelitian ini merupakan penelitian kuantitatif dengan desain cross-sectional menggunakan pendekatan observasional, di mana pengumpulan data dilakukan secara bersamaan pada satu waktu sehingga setiap subjek penelitian hanya diobservasi satu kali. Sampel dalam penelitian ini merupakan perawat pelaksana yang bekerja di ruang rawat inap Rumah Sakit Dr. Hafiz Cianjur. Teknik pengambilan sampel menggunakan probability sampling dengan pendekatan proportionate stratified random sampling dengan 106 responden. Uji analisis bivariat dalam penelitian menggunakan uji chi-square dan fisher’s exact test. Hasil: Hasil analisis hubungan antara literasi digital dan supervisi kepala ruangan dengan kesesuaian dokumentasi asuhan keperawatan berbasis Electronic Medical Record (EMR) menunjukkan nilai p-value masing-masing sebesar 0,000 dan 0,004 (p < 0,05), sehingga hipotesis nol (H₀) ditolak dan hipotesis alternatif (Hₐ) diterima. Kesimpulan: Simpulan penelitian ini menunjukkan bahwa terdapat hubungan yang signifikan antara literasi digital dan supervisi kepala ruangan dengan kesesuaian dokumentasi asuhan keperawatan berbasis Electronic Medical Record di ruang rawat inap Rumah Sakit Dr. Hafiz Cianjur.

Kata Kunci: Literasi Digital, Supervisi Kepala Ruangan, Kesesuaian Dokumentasi Asuhan Keperawatan, Rekam Medis Elektronik 

Abstract

Introduction: Nursing care documentation is an important part of medical records. In today's digital era, nursing care documentation has shifted to electronic medical records (EMR), which require complete, systematic, and standardized data entry. Therefore, nurses' digital literacy and ward head supervision play a crucial role in ensuring the appropriateness of nursing care documentation in inpatient wards. Objective: The purpose of this study was to determine the relationship between digital literacy and ward head supervision and the appropriateness of electronic medical record-based nursing care documentation in the inpatient wards of Dr. Hafiz Hospital, Cianjur. Methods: This study was a quantitative study with a cross-sectional design using an observational approach, where data collection was carried out simultaneously at one time so that each research subject was only observed once. The sample in this study were nurses working in the inpatient wards of Dr. Hafiz Hospital, Cianjur. The sampling technique used probability sampling with a proportionate stratified random sampling approach with 106 respondents. Bivariate analysis tests in the study used the chi-square test and Fisher's exact test. Results: The results of the analysis of the relationship between digital literacy and supervision of the head of the room with the suitability of nursing care documentation based on Electronic Medical Record (EMR) showed p-values ​​of 0.000 and 0.004 (p < 0.05), respectively, so that the null hypothesis (H₀) was rejected and the alternative hypothesis (Hₐ) was accepted. Conclusion: The conclusion of this study shows that there is a significant relationship between digital literacy and supervision of the head of the room with the suitability of nursing care documentation based on Electronic Medical Record in the inpatient ward of Dr. Hafiz Hospital Cianjur.

Keywords: Digital Literacy, Supervision of the Head of the Room, Compliance of Nursing Care