GAMBARAN PENDOKUMENTASIAN LAPORAN ANESTESI DI INSTALASI BEDAH SENTRAL RUMAH SAKIT DAERAH MANGUSADA D.P.Eka Noviani Fakultas Kesehatan Program Studi D IV Keperawatan Anastesiologi Institut Teknologi dan Kesehatan Bali Email: [email protected] ABSTRAK Latar Belakang: Kelengkapan laporan anestesi sangat penting sebagai indikator keselamatan pasien. Namun, laporan anestesi masih ditemukan tidak lengkap. Padahal pencatatan laporan anestesi yang komprehensif pada pre, intra, dan pasca anestesi diperlukan. Tujuan: Penelitian ini bertujuan untuk mengetahui gambaran pendokumentasian laporan pra anestesi, intra anestesi dan pasca anestesi di Instalasi Bedah Sentral Rumah Sakit Daerah Mangusada. Metode: Penelitian deskriptif dengan pendekatan cross sectional dilakukan pada tanggal 28 April-28 Mei 2023. Sampel terdiri dari 249 formulir laporan anestesi kasus bedah yang diambil dengan teknik convenience sampling. Instrumen penelitian menggunakan check list. Data di analisis secara univariat. Hasil: Mayoritas laporan anestesi merupakan jenis pembedahan elektif (69%) dengan bedah umum sebagai kategori pembedahan dominan (31%). Mayoritas pendokumentasian laporan pra anestesi (71%), intra anestesi (98%) dan pasca anestesi (97%) termasuk kategori lengkap. Namun, pada laporan pra anestesi terdapat kekurangan pada item laboratorium seperti haemoglobin, hematokrit, trombosit, urinalisis, elektrolit, lainnya dan daftar masalah/diagnosis. Secara keseluruhan 70% laporan anestesi terisi lengkap. Kesimpulan: Mayoritas laporan anestesi pra, intra, dan pasca anestesi termasuk pada kategori lengkap, Namun, perlu perbaikan pada pendokumentasian item laboratorium. Diharapkan adanya sosialisasi dan monitoring secara berkala untuk meningkatkan kualitas dokumentasi laporan anestesi. Kata Kunci: Laporan anestesi, pendokumentasian

THE DOCUMENTATION OF ANESTHESIA REPORTS IN CENTRAL SURGICAL INSTALLATIONS OF MANGUSADA HOSPITAL D.P.Eka Noviani Faculty of Health Diploma IV Nursing Anesthesiology Institute of Technology and Health Bali Email: [email protected] ABSTRACT Background: The anesthesia report completeness is very important as an indicator of patient safety. However, the anesthetic reports were found to be incomplete. A comprehensive record-keeping of anesthesia reports on pre, intra, and post anesthesia is required. Purpose: To describe the documentation of anesthesia reports in central surgical installations of Mangusana hospital Methods: This study employed descriptive design with cross sectional approach that was conducted on April 28-May 28, 2023. There were 249 anesthesia surgical case report forms used in this study and taken by using convenience sampling technique. The data were collected by using check list to assess the completeness of the anesthesia report documentation. The data were analysed by using univariate analysis. Results: The finding showed that the majority of anesthesia reports were elective types of surgery (69%) and general surgery being the dominant surgical category (31%). The majority of pre-anesthesia (71%), intra-anesthesia (98%) and post-anesthesia (97%) reports were included in the complete category. However, in the pre-anesthesia report there was a lack of evaluation of laboratory results such as hemoglobin, hematocrit, platelets, urinalysis, electrolytes, others and a list of problems/diagnosis. Overall 70% of anesthesia reports were completed. Conclusion: The majority of pre-, intra-, and post-anesthesia reports are included in the complete cdocuments. However, the improvement is needed on the documentation of laboratory items. It is expected to organized a regular socialization and monitoring to improve the quality of documentation of anesthesia reports. Keywords: Anesthesia Report, Documentation