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EVALUASI KELENGKAPAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUANG PERAWATAN LANTAI III RUMAH SAKIT ADVENT BANDUNG

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ABSTRACT EVALUATION OF DETERMINATION OF NURSING INSTITUTION OF NURSING ASSEMBLY TREATMENT FLOOR III ADVENT BANDUNG HOSPITAL PUTRI TINGGI LIKULA’BI NIM: 1351018 Documentation of nursing care is part of the responsibility. Health information, health care, medication and treatment. This study aims to obtain a description of the assessment of the completeness of documenting nursing care in the third floor treatment room of Adventist Hospital Bandung. The method used in this research is descriptive qualitative. Instruments used in this study. The results showed the implementation of documenting nursing care in the floor ward of Advent Bandung Hospital is in incomplete category with an average value of 69.87%. Aspects carried out according to the procedures in documenting nursing care in the third floor treatment room of Advent Bandung Hospital were the intervention aspect (80.5%) in the south wing space and the assessment (70.75%) in the west wing room. Aspects not performed according to procedures in documenting nursing care in the third floor treatment room of Advent Bandung Hospital were evaluation (66.67%) in south wing space and nursing diagnosis (53.2%) in west wing space. Expected nursing field, follow up incomplete data, enforce reinforcement system (Law, Reward) and improve continue nursing training for accurate and correct writing of the nursing institution. Field of nursing audit, using random method when conducting auditing documentation and add some CI (Clinical Instructor) nursing. Field research, this study can be developed for further research. Research can use other methods, such as the use of the latest nursing institution format conducted ar Advent Bandung Hospital. Keywords: Nursing Care Documentation, Nursing Care Evaluation.