KAJIAN LITERATUR: AUDIT DOKUMENTASI KEPERAWATAN
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Abstract
Tujuan: Mengetahui proses dan manfaat audit dokumentasi keperawatan
Metode: Pencarian elektronik melalui database PubMed, Scopus, Science Direct, EBSCOhost, ProQuest, Google Scholars. Kemudian dilanjutkan dengan proses pengembangan PRISMAgroup/ flow diagram yang dilanjutkan dengan penyusunan matriks sintesis berdasarkan tujuan, kriteria inklusi dan eksklusi. Informasi tentang tujuan, sampel, desain, instrument, hasil setiap studi dirangkum dan dianalisis.
Hasil: Review menunjukkan tujuh artikel lolos uji skrining. Tujuan audit dokumentasi keperawatan adalah untuk meningkatkan mutu asuhan keperawatan dan keselamatan pasien. Audit dokumentasi dapat menunjukkan kualitas dokumentasi yang masih kurang atau belum sesuai standar yang ditetapkan. Upaya yang dapat dilakukan adalah pemberian dukungan dari pemerintah melalui penetapan kebijakan standar dokumentasi keperawatan. Proses audit dokumentasi keperawatan dapat dilakukan melalui review catatan rekam medik pasien baik secara retrospektif maupun concurrent dengan menggunakan instrument audit yang sudah melalui uji validitas dan reliabilitas.
Kesimpulan: Pelaksanaan audit dokumentasi keperawatan memerlukan dukungan dari pemerintah, organisasi profesi, dan fasilitas pelayanan kesehatan baik dalam penyusunan standar, penetapan instrument untuk pelaksanaan audit, maupun lembaga yang melakukan proses audit.
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