HUBUNGAN ANTARA PENGETAHUAN PERAWAT DENGAN KELENGKAPAN PENDOKUMENTASIAN DIAGNOSIS KEPERAWATAN BERBASIS STANDAR DIAGNOSIS KEPERAWATAN INDONESIA DI RUANG RAWAT INAP RUMAH SAKIT UMUM BALI MANDARA Ni Wayan Iin Rahayu Fakultas Kesehatan Program Studi Sarjana Keperawatan Institut Teknologi dan Kesehatan Bali Email : [email protected] ABSTRAK Latar Belakang. Pengetahuan perawat terkait indikator-indikator diagnostik untuk penegakan diagnosis masih perlu ditingkatkan agar penegakan dapat dilakukan secara tepat dan terstandarisasi. Masih ditemukan pendokumentasian diagnosis keperawatan yang dibuat hanya mencantumkan komponen masalah keperawatan saja. Tujuan. Untuk mengetahui hubungan antara pengetahuan perawat dengan kelengkapan pendokumentasian diagnosis keperawatan berbasis Standar Diagnosis Keperawatan Indonesia Metode. Penelitian ini menggunakan desain deskriptif korelatif dengan pendekatan cross-sectional. Populasi penelitian ini adalah perawat ruang rawat inap Rumah Sakit Umum Bali Mandara. Waktu penelitian pada bulan Maret sampai April 2022. Sampel sebanyak 77 responden diambil menggunakan teknik total sampling. Instrumen yang digunakan berupa kuesioner dengan google form untuk pengetahuan perawat dan lembar observasi untuk kelengkapan pendokumentasian diagnosis keperawatan. Teknik analisa data menggunakan uji Spearman’s Rho. Hasil. Hasil penelitian ini menunjukkan sebanyak 55 responden (71,4%) dengan tingkat pengetahuan baik dan sebanyak 55 responden (71,4%) dengan tingkat kelengkapan pendokumentasian diagnosis keperawatan lengkap. Terdapat hubungan positif yang signifikan antara pengetahuan perawat dengan kelengkapan pendokumentasian diagnosis keperawatan berbasis Standar Diagnosis Keperawatan Indonesia (r = 0,74, p-value

THE CORRELATION BETWEEN THE KNOWLEDGE OF NURSE AND COMPLETENESS OF NURSING DIAGNOSES DOCUMENTATION BASED ON INDONESIAN NURSING DIAGNOSES STANDARDS IN THE INPATIENT ROOM OF BALI MANDARA GENERAL HOSPITAL Ni Wayan Iin Rahayu Faculty of Health Bachelor of Nursing Study Program Institute of Technology and Health Bali Email : [email protected] ABSTRACT Background. Nurses' knowledge of diagnostic indicators for diagnosis enforcement still needs to be improved so that enforcement can be carried out appropriately and standardized. It is still found that the documentation of nursing diagnoses made only lists the components of nursing problems. Aim. To find out the correlation between nurses’ knowledge and the completeness of nursing diagnosis documentation based on Indonesian Nursing Diagnosis Standards. Method. This study employed descriptive correlative design with a cross-sectional approach. The population of this research is the inpatient room nurses at Bali Mandara General Hospital. The research time is from March to April 2022. A sample of 77 respondents who were taken using the total sampling technique. The instruments used was a questionnaires with google forms for nurse knowledge and observation sheets for completeness of documenting nursing diagnoses. The data were analyzed technique using Spearman's Rho test. Result. The results of this study showed as many as 55 respondents (71.4%) had a good level of knowledge and 55 respondents (71.4%) had a complete level of documentation of a complete nursing diagnosis. There is a significant correlation between the knowledge of nurses and the completeness of documentation nursing diagnosis based on the Indonesian Nursing Diagnosis Standard (r = 0,74, p-value