| Summary: | Background: Documentation of nursing care is a record of the patient's
condition while being treated, as well as on the provision of treatment or
action given by nurses to patients. Documentation of nursing has an
important meaning viewed from various aspects such as legal aspects,
quality of service, communication, finance, education, research, and
accreditation. As the initial process of nursing care, nursing assessment is
very important because it becomes the initial data of the next phase of
nursing care. Based on a preliminary study conducted in Muhammadiyah
Sruweng Hospital, researchers found an incompleteness in nursing
assessment. In addition, researchers also found a difference of length of
employment in each of the length of nurses working at Sruweng
Muhammadiyah Hospital.
Objective: To determine the characteristics of survey respondents are
nurses (gender, education last, employment status, and length of work).
Knowing completeness nursing assessment sheets adults and children in
Muhammadiyah Sruweng Hospital. Knowing the relationship the length of
nurses with nursing assessment completeness inpatient medical record
file in Muhammadiyah Sruweng Hospital.
Methods: This type of research is inferential quantitative approach with a
cross-sectional design. The samples taken were 96 nurses gained through
study of documentation in the personnel department and 337 inpatient
medical record file of the month from October to December 2013, which is
obtained through the study documentation. Data collection techniques is
the study documentation. Analysis using Spearman rank statistical test.
Results: The results showed that the respondents' sex male respondents
16,67 %, while 83,33 % are female . Respondents to the Diploma Nursing
Education last totaled 91,70 %, totaling 4,20 % SPK, S1 Nursing and
nurses totaled 1,00%, and amounted to 3,10% Nursing S1. Respondents
with permanent employment status amounted to 26,00% while the nonpermanent
employees amounted to 74,00%. Respondents were included
in the new category of length of service amounted to 57,30%, while
respondents in the category of long length of service amounted to 42,70%.
File medical records entered into the bad category is 53,41%, while the
medical record file in either category is 46,59 %. There is a long term
relationship with a nurse working completeness inpatient medical record
file ( significance (p) = 0,0001 and the correlation coefficient (r) = -0,216).
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