Published date: Dec 23 2019

Journal Title: KnE Life Sciences

Issue title: The First International Conference on Health Profession

Pages: 196–209

DOI: 10.18502/kls.v4i15.5759

Amira .Health Polytecnic of Ternate, North of Maluku, Indonesia, Diploma in Nursing Program

Muhlisa .Health Polytecnic of Ternate, North of Maluku, Indonesia, Diploma in Nursing Program

Tri JohanHealth Polytecnic of Malang, East Java, Indonesia, Diploma in Nursing Program

Completeness of nursing documentation is one of the quality indicators of nursing care. Based on the nursing practice law no. 38 article 37, nurses in carrying out Nursing Practices are obliged to document Nursing Care in accordance with the standards. Documentation in Inpatient PKM consisting of Siko, Jambula, and Sulamadaha PKM itself, based on the observations of researchers found several obstacles, namely, the lack of nurses given the large number of PKM programs that must be run, varying levels of education so documentation has a different understanding, this also supported by the lack of education and training related to temporary nursing care documentation relating to the Nursing Process and Documentation experiencing some recent changes. The purpose of this study was to determine the effect of applying the nursing documentation format for the model Problem-Oriented Record (POR) on the performance of nurses in the Inpatient Health Center in Ternate City. The design of this study is quasi-experimental, namely, pre and post-test without control group. The population is nurses with 41 people in PKM Inpatient who are in Ternate City. Samples were taken by total sampling technique and analyzed using statistical tests t-test, Anova, and correlation. The results of the study found a significant difference between the performance of nurses before and after the application of the documentation format for nursing care in the POR model (p-value: 0,0005 α: 0.05) while the characteristics of respondents included age, sex, marital status, length of work and education had no effect on performance.

[1] Alkouri, O., Alkhatib, A., &Kawafhah, M. (2016). Importance And Implementation Of Nursing Documentation: Review Study.EuropeanScientificJournal, 12(3), 101–106. http://doi.org/10.19044/esj

[2] AmiraBSA. (2008). Effect of Conflict Management Training on the Head of the Room on the Performance of Executing Nurses at the Marzoeki Mahdi Hospital in Bogor. FIK-UI Postgraduate Program Thesis. Jakarta. Unpublished.

[3] Ardenny, &Hirzal. (2016). Effectiveness of Nursing Documentation Format Problem Oriented Record Model (POR) on the Ease of Use by Nurses in Outpatient Hospital PetalabumiPekanBaru. Health Journal of Health Polytechnic Ministry of Health, PekanBaru, 3, 366–376.

[4] Blair and Smith, W. and B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse: A Journal for the Australian Nursing Profession, 41(2), 160–168. http://doi.org/10.5172/conu.2012. 41.2.160

[5] Gillies, DA (1994).Nursing management: a systems approach. 3rd ed. Philadelphia: WB Saunders Company.

[6] Gibson, JL, Ivancevich, JM, Donnely, JH (1996). Organization and Management - behavior, structure, process. Jakarta: Erlangga.

[7] Gustomi, MP, Churin’in. (2015). Application of Nursing Care Documentation Model Problem Oriented Record (POR) Against Nurse’s performance. 6 (02), Journal of Nurses Community. http://journal.unigres. ac.id/index.php/JNC/article/view/46


[8] Hastono, SP (2007). Basic Data Analysis For Health Research. Depok: FKM UI.

[9] Ilyas, Y. (2002). Performance; theory, assessment and research. Third print. Depok; FKM UI Health Economics Study Center.

[10] Permenkes No. 44. Management Guidelines for Puskesmas, Pub. L. No. 44 (2016). Indonesia: Ministry of Health.

[11] President of the Republic of Indonesia. Nursing Practice Act (2014). Indonesia: Ministry of Health.

[12] Putra, AA (2016). Relationship between nurses’ perceptions about the characteristics of their work with compliance in documenting nursing care. Diponegoro University.

[13] Panjaitan, R. (2004). Executing Nurse Perception of Organizational Culture and Its Relationship with Performance at the Marzoeki Mahdi Hospital in Bogor. FIK-UI Postgraduate Program Thesis. Jakarta. Not published.

[14] Robbins, S, P. (2006). Organizational behavior. Tenth edition. Jakarta; PT. Gramedia Index.

[15] Simanjuntak P, J. (2005). Performance Management and Evaluation. First print. Depok; FE-UI Publishing Agency.

[16] Siagian, SP (2000). Theory and Practice of Leadership. Fifth print. Jakarta: PT. RinekaCipta.

[17] Simamora, R. (2005). Relationship between Executing Nurses’ Perceptions of the Implementation of Organizing Functions Performed by the Head of the Room with Performance in the Inpatient Room of RsudKoja, North Jakarta. FIK-UI Postgraduate Program Thesis. Jakarta. Unpublished.

[18] Tafwidhah, Y, Nurachmah, E, Hariyati TS (2012). Indonesian Nursing Journal, 15 (1), 21-28. jki.ui.ac.id/index.php/jki/article/v iew /43