GAMBARAN KELENGKAPAN PENDOKUMENTASIAN ASUHAN KEPENATAAN ANESTESI PADA PASIEN YANG MENJALANI TINDAKAN ANESTESI DAN PEMBEDAHAN DI IBS RUMAH SAKIT UMUM DAERAH KABUPATEN RAJA AMPAT Maurinus Maring, Fakultas Keseshatan Program Studi D - IV Keperawatan Anestesiologi Institut Teknologi dan Kesehatan ( ITEKES ) Bali. Email: [email protected] Abstrak Latar belakang: Kelengkapan pendokumentasian asuhan kepenataan anestesi merupakan salah satu fungsi yang paling penting. Saat ini sistem pelayanan kesehatan memerlukan dokumentasi yang yang menjamin kesinambungan perawatan, melengkapi bukti hukum, proses pelayanan dan mendukung kualitas pelayanan pasien. Tujuan penelitian : Un tuk mengetahui gambaran kelengkapan pendokumentasian asuhan kepenataan anestesi pada pasien yang menjalani tindakan anestesi dan pembedahan di IBS R SUD Kab . Raja Ampat. Metode : Metode yang dipakai dalam penelitian ini adalah deskriptip kuantitatif dengan pendekatan cross sectional , populasi target dalam penelitian ini adalah semua dokumentasi asuhan kepenataan anestesi dengan sampel sebanyak 50 dokumen. Hasil penelitian : uji statistic m enunjukan kelengkapan pendokumentasian asuhan kepenataan anestesi pada tahap pengkajian , analisa data/masalah, rencana intervensi dan implementasi 100 % tidak lengkap sedangkan tahap evaluasi hanya mencapai 24 % lengkap dan serah terima me ncapai 76 % lengkap. Kesimpulan: P elaksanaan pendokumentasian asuhan kepenataan anestesi tidak semuanya dilaksanakan dengan baik untuk itu perlu lebih digiatkan lagi. Kata Kunci: Dokumentasi Asuhan Kepenataan Anestesi, Penata Anestesi.

THE COMPLETENESS OF ANESTHESIA CARE DOCUMENTATIONIN PATIENT UNDERGOING ANESTHESIA AND SURGE R Y AT IBS OF RAJA AMPAT HOSPITAL Maurinus Maring Faculty of Health Diploma IV of Nursing Anesthesiology Program Institute of Technology and Health Bali Email: [email protected] A BSTRACT Background : The completeness of anesthesia care documentation is one of the most important function. Currently, the health care system requires documentation ensures the continuity of care, the complements of legal evidence, service processes and supports the quality of patient care. Aim : To determine the completeness of anesthesia care documentation in patient undergoing anesthesia and surgery at IBS of Raja Ampat Hospital Method : This s tudy employed descriptive quantitative design with cross sectional approach. The population of this study was documentation of anesthesia care. There were 50 anesthesia care documentation used in this study. Result : The finding showed that there were 50 doc umentations (100%) of anesthesia care in assessment stage, data analysis/problem, intervention plan and the implementation were incomplete. There were 12 documentations (24%) in evaluation stage were complete and there were 38 documentations (76%) inhandov er stage were complete Conclusion : The documentation of anesthesia care are not well implemented at Raja Ampat Hospital.It needs to be further encouraged. Keywords : Anesthesia Care Documentation , Nurse Anesthetist