Latar Belakang: Rumah sakit sebagai pemberi jasa layanan kesehatan dituntut untuk memberikan layanan yang berkualitas. Pelayanan yang berkualitas dapat diwujudkan melalui dokumentasi berupa catatan perawatan klien. Dokumentasi asuhan keperawatan harus dilakukan dengan baik untuk memastikan keamanan dan kualitas pelayanan kesehatan. proses asuhan keperawatan telah dilakukan dengan baik oleh perawat pelaksana, tetapi untuk proses dokumentasi masih sangat kurang. Kelengkapan dokumentasi pada proses asuhan keperawatan kurang dari 50%. Supervisi kepala ruang sebagai first line manager di RS X Kota Ambon pada pendokumentasian asuhan keperawatan tidak optimal karena belum adanya pelatihan. Tujuan: untuk mengetahui dokumentasi asuhan keperawatan oleh perawat pelaksana setelah pelatihan supervisi kepala ruang di Rumah Sakit X Kota Ambon. Metode: Metode penelitian pra-eksperimental one group pre-test post-test design. Jumlah sampel dalam penelitian ini sebanyak 40 responden. Hasil: Hasil Penelitian menunjukkan pelatihan supervisi kepala ruang, dan pendampingan implementasi supervisi selama 1 minggu dapat meningkatkan skor pendokumentasian asuhan keperawatan (pengkajian, diagnosis, intervensi, implementasi, dan evaluasi) secara bermakna (p < 0.050). Tidak ada hubungan antara antara umur (p=1.926), Jenis kelamin (p=0.943), Pendidikan (p=0.173), dan lama kerja (p=0.195) dengan pendokumentasian asuhan keperawatan setelah pelatihan supervise kepala ruang di Rumah Sakit X Kota Ambon. Kesimpulan dan Saran: Rentang usia perawat 20-40 tahun (77.5%), jenis kelamin perempuan (82,5%), pendidikan D3/S1 Keperawatan (82,5%) dan lama kerja lebih dari 6 tahun (65%). Skor pendokumentasian meningkat secara bermakna (p < 0.050) setelah dilakukan pelatihan supervisi kepala ruang, dan pendampingan implementasi supervisi. Tidak ada hubungan antara antara umur (p=1.926), Jenis kelamin (p=0.943), Pendidikan (p=0.173), dan lama kerja (p=0.195) dengan pendokumentasian asuhan keperawatan setelah pelatihan supervisi kepala ruang di Rumah Sakit X Kota Ambon. Penelitian ini merekomendasikan intensitas supervisi kepala ruang harus dipertahankan dan dilakukan secara teratur serta berkelanjutan agar perawat pelaksana dapat temotivasi dalam meningkatkan pendokumentasian yang berorientasi pada pelayanan asuhan keperawatan yang berkualitas.
Background: Hospitals as health service providers are required to provide quality services. Quality service can be realized through documentation in the form of client care records. Nursing care documentation must be done properly to ensure the safety and quality of health services. The nursing care process has been carried out well by the implementing nurse, but the documentation process is still lacking. The completeness of documentation in the nursing care process is less than 50%. Supervision of the head of the room as the first-line manager at RS X Ambon City in documenting nursing care was not optimal because there was no training. Aims: to find out the documentation of nursing care by the nurse executing after the training in the supervision of the head of the room at Hospital X Ambon CityMethods. Method: The method of pre-experimental research one group pre-test post-test design. The number of samples in this study were 40 respondents. Result: The results showed that training in the supervision of the head of the room, and assistance in implementing supervision for 1 week could significantly increase the score of nursing care documentation (assessment, diagnosis, intervention, implementation, and evaluation) significantly (p <0.050). There was no relationship between age (p = 1,926), gender (p = 0.943), education (p = 0.173), and length of work (p = 0.195) with documentation of nursing care after training in supervise headroom at Hospital X Ambon City. Conclusion: The age range of nurses was 20-40 years (77.5%), female gender (82.5%), D3 / S1 Nursing education (82.5%), and work duration more than 6 years (65%). The score for documentation increased significantly (p <0.050) after training on the supervision of the head of the room, and assistance in implementing supervision. There was no relationship between age (p = 1,926), gender (p = 0.943), education (p = 0.173), and length of work (p = 0.195), and documentation of nursing care after training in the supervision of the head of room at Hospital X Ambon City.
Effect of End-of-Life Nursing Education on the Knowledge and Performance of Nurses in the Intensive Care Unit: A Quasi-Experimental Study