The Effectiveness and Efficiency of Nursing Care Documentation Using the SIMPRO Model

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Abstract

PURPOSE:

The study aims to develop and test the effectiveness and efficiency of the SIMPRO. SIMPRO was developed with NANDA-I, Nursing Intervention Classification, and Nursing Outcome Classification nursing language.

METHOD:

The research was divided into two parts, in which we used two different designs—incremental and quasi-experimental design. Two hundred fifty-five samples of nursing documentations were randomly assessed with computer-assisted clustering out of 1,040 nursing records of discharged patients. Data were analyzed using Wilcoxon test to compare each elements of evaluation before and after the implementation of the system.

RESULT:

SIMPRO improved the quality of documentation (p = .0001) and time efficiency (p = .0001).

CONCLUSION:

SIMPRO increased the quality and functions of the decision support system in delivering nursing care as well as in nursing management.

TUJUAN:

Penelitian ini bertujuan untuk mengembangkan dan menguji keefektifan dan efisiensi SIMPRO. SIMPRO adalah sistem informasi manajemen keperawatan yang dikembangkan dengan menggunakan NANDA-I, Nursing Intervention Classification dan Nursing Outcome Classification.

METODE:

Penelitian ini dibagi menjadi dua tahap yang menggunakan desain incremental dan kuasi-eksperimental. 255 sampel dokumentasi keperawatan diambil secara acak dengan menggunakan klustering yang dibantu dengan komputer dari 1040 catatan keperawatan pasien yang sudah pulang. Data dianalisis dengan Uji Wilcoxon untuk membandingkan masing-masing elemen sebelum dan sesudah implementasi sistem.

HASIL:

SIMPRO memperbaiki kualitas dokumentasi (p = .0001) dan efisiensi (p = .0001).

KESIMPULAN:

SIMPRO meningkatkan kualitas dan fungsi sistem dukungan dalam memberikan asuhan keperawatan dan manajemen keperawatan.

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