Manajemen assessment awal pasien rawat inap Penyakit Dalam

Abstract

Inpatient care is an important part of the healthcare system, especially for internal medicine patients who generally have complex medical conditions and require continuous monitoring. One important stage in this service is the initial patient assessment, which serves as the basis for determining the diagnosis, planning actions, and making clinical decisions during the care process. This study aims to analyze the implementation of initial assessment management in internal medicine inpatients and describe the factors that influence it. The study used a descriptive quantitative method with an observational analytical approach and a cross-sectional design. The study was conducted in the internal medicine inpatient unit of a type C hospital in South Sumatra Province for three weeks in December 2025, with a sample of 23 nurses who met the inclusion criteria. Data were collected using a questionnaire compiled based on the nursing assessment format and analyzed descriptively. The results showed that the majority of respondents were early adults (82.6%), female (69.6%), had a nursing education (82.6%), and had a new work experience (65.2%). In general, the initial nursing assessment has been carried out quite well, including baseline data assessment, physiological status, patient risk, and discharge planning. However, several challenges remain, such as time constraints, inconsistencies in documentation, and suboptimal monitoring and evaluation. Therefore, strengthened supervision, standardized procedures, and improved workload management are needed to enhance the quality of initial assessments for inpatients with internal medicine.