Proper, readable, and complete documentation will have an impact on the quality of care and defense of potential malpractice suits, may be used as legal evidence in the event of a claim, but much of the nursing documentation is found to be incompatible or does not contain the necessary information in the case of the judiciary, lack of records or documentation in the patient's medical record often hampers the exercise of the protection of nursing professional rights, both legally and administratively. The purpose of this research is to know the relation of workload factor based on workload assessment with the completeness of nursing care documentation by the nurses in the room IGD RSU. Anutapura Palu and RSU. Undata Palu. This research use correlation analytic design with cross sectional approach with total sampling to 65 samples period from 25 March 2017 until 25 April 2017. in IGD RSU room. Anutapura Palu and RSU. Undata Palu. From result of bivariate analysis known that there is correlation between work load factor with completeness of nursing care documentation with p value = 0,022. The result of regression test showed that the work load factor has regression coefficient value is -15.648 (negative value), which means that the higher workload, the percentage of completeness of the documentation of nursing care will be lower. ABSTRAKDokumentasi yang tepat, mudah dibaca, dan lengkap, akan berdampak pada kualitas perawatan dan pertahanan dari potensial gugatan malpraktik, dapat digunakan sebagai bukti hukum apabila terjadi tuntutan, tetapi banyak dokumentasi keperawatan yang ditemukan tidak sesuai atau tidak mengandung informasi yang diperlukan dalam kasus peradilan, serta kurangnya catatan atau dokumentasi dalam rekam medis pasien sering menghambat pelaksanaan perlindungan hak-hak profesional keperawatan, baik secara hukum maupun administratif. Tujuan penelitian ini adalah untuk mengetahui hubungan faktor beban kerja berdasarkan penilaian workload dengan kelengkapan dokumentasi asuhan keperawatan oleh perawat pelaksana di ruang IGD RSU. Anutapura Palu dan RSU. Undata Palu. Penelitian ini menggunakan desain analitik korelasi dengan pendekatan cross sectional dengan total sampling terhadap 65 sampel periode 25 Maret 2017 sampai dengan 25 April 2017. di ruang IGD RSU. Anutapura Palu dan RSU. Undata Palu. Dari hasil analisis bivariat diketahui bahwa terdapat hubungan antara faktor beban kerja dengan kelengkapan dokumentasi asuhan keperawatan dengan p value = 0,022. Hasil uji regresi linear didapatkan faktor beban kerja mempunyai nilai koefisien regresi adalah -15,648 (bernilai negatif), yang berarti bahwa semakin tinggi beban kerja, maka persentase kelengkapan dokumentasi asuhan keperawatan akan semakin rendah.
Proper, readable, and complete documentation will have an impact on the quality of care and defense of potential malpractice suits, may be used as legal evidence in the event of a claim, but much of the nursing documentation is found to be incompatible or does not contain the necessary information in the case of the judiciary, lack of records or documentation in the patient's medical record often hampers the exercise of the protection of nursing professional rights, both legally and administratively. The purpose of this research is to know the relation of workload factor based on workload assessment with the completeness of nursing care documentation by the nurses in the room IGD RSU. Anutapura Palu and RSU. Undata Palu. This research use correlation analytic design with cross sectional approach with total sampling to 65 samples period from 25 March 2017 until 25 April 2017. in IGD RSU room. Anutapura Palu and RSU. Undata Palu. From result of bivariate analysis known that there is correlation between work load factor with completeness of nursing care documentation with p value = 0,022. The result of regression test showed that the work load factor has regression coefficient value is-15.648 (negative value), which means that the higher workload, the percentage of completeness of the documentation of nursing care will be lower.
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