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Dokumentasi Proses Keperawatan

By:

Ns. Anisah Ardiana, M.Kep.

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Standar kompetensi

Mahasiswa mampumenerapkanpendokumentasian proseskeperawatan dalammemberikan asuhankeperawatan dengan penuhtanggung jawab dan

profesional.

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Kompetensi dasar:

Mahasiswa dapat menjelaskan konsep dasar

pendokumentasian proses keperawatan meliputi:

Sejarah

Pengertian pendokumentasian

Tujuan pendokumentasian Komponen dokumentasi

Keuntungan pendokumentasian proses keperawatan

bagi perawat, tim kesehatan, dan pasien

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Sejarah:

Bekerja ----- instruksi dokterfokus penyakit

1955, Linda Hall nursing process

1967 Catholic university -----pengkajian, perencanaan, intervensi,

evaluasi

1982 National Council of State Boards

of nursing ----- assessment, analyzing,planning, implementation, evaluation

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Nightingale described the need fornurses to record "the proper use of

fresh air, light, warmth, cleanliness,

& the proper selection &

administration of diet". Pada masa Nightingale,

dokumentasi dipakai sebagai cara

untuk mengkomunikasikan

pelaksanaan tindakan sesuai ordermedis, bukan sebagai alat untuk

mengkaji status pasien, seperti pada

zaman sekarang.

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Whats Documentation?......

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Anything written or printed record of

activities.

Vital part of professional practice

Pencatatan dan pelaporan merupakan

cara utama para pemberi pelayanan

kesehatan dalam berkomunikasi

The clients medical record is a legal

document of all activities regarding

client care.

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Documentation is written evidence of:

The interactions between and amonghealth care professionals, clients, their

families, and health care organizations.

The administration of tests, procedures,treatments, and client education.

The results of, or clients response to,

diagnostic tests and interventions

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Proses: serangkaian tindakan yang direncanakan

untuk mencapai tujuan

Proses keperawatan (nursing process): systematic,rational methodes of planning and providing nursing

care

The Nursing ProcessLangkah-langkah pemecahanmasalah yang digunakan untuk mengidentifikasi dan

mengatasi masalah kesehatan pasien.

a systematic approach to nursing which comprises a

series of steps which, most commonly, are referredto as assessing, planning, implementing and

evaluating.

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Karakteristik nursing process:

Based on knowledge-requiring critical

thinking

Planned-organized and systematic

Client-centered

Goal-directed Prioritized

Dynamic

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Manfaat menggunakan nursing process:

Continuity of care

Prevention of duplication

Individualized care

Standards of care Increased client participation

Collaboration of care

Stresses the independent function of nurses Increases care quality through the use of deliberate

actions

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Tujuan pendokumentasian:

Communication

Practice and legal standards

Reimbursement

Education

Research

Nursing audit

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Documentation as communication

Documentation is a communicationmethod that confirms the care provided

to the client.

It clearly outlines all importantinformation regarding the client.

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Documentation as legal and practice

standard

Nurses are responsible for assessing anddocumenting that the client has an

understanding of treatment prior tointervention.

Two indicators of the above are

Informed Consent and AdvanceDirectives.

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Informed consent

Kemampuan klien (yang berkompeten) untukmembuat keputusan mengenai perawatannya

berdasarkan manfaat, risiko, konsekuensinya

terhadap rencana tindakan yang

dirokemendasikan

Persetujuan klien terhadap tindakandibuktikan dengan tanda tangan klien pada

lembar consent (lembar persertujuan)

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Documentation and reimbursement

Institusi perlu memonitor dan mengevaluasikualitas dan ketepatan pemberian pelayanan

Dokumen (laporan dan pencatatan) mengenai

pelayanan yang diberikan dapat menjadiacuan pemberian kompensasi (bayaran)

Failure to document can result in

reimbursement denied.

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Documentation as education

Health care students use medical record as ateaching tool (alat pembelajaran) to learn

about disease processes, nursing diagnoses,

complications and interventions.

Mahasiswa dapat meningkatkan kemampuan

berpikir kritis dengan mempelajari

dokumentasi (pencatatan) dan ikut dalam tim

perawat yang melakukan perencanaanpelayanan kep.

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Documentation and research

Dokumen pasien dapat menjadi sumber datauntuk melakukan penelitian klinis.

The clients medical record is used by

researchers --- untuk menentukan apakahkondisi klien sesuai dengan penelitian yang

akan dilakukan.

Documentation can also indicate a need forresearch.

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Documentation and nursing audit

Method of evaluating the quality of care Includes:

Safety measures

Treatment interventions and responsesExpected outcomes

Client teaching

Discharge planningAdequate staffing

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Komponen dokumentasi:

Elements of nursing process needed to be madeevident in documentation include:

Assessment.

Nursing Diagnosis. Planning and outcome identification.

Implementation.

Evaluation.

Revisions of planned care.

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PRINCIPLES OF EFFECTIVE

DOCUMENTATION

Document accurately, completely, and objectively, including

any errors.

Note date and time.

Use appropriate forms.

Identify the client. Write in ink.

Use standard abbreviations.

Spell correctly.

Write legibly.

Correct errors properly.

Write on every line.

Chart omissions.

Sign each entry.

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Lakukan wawancara singkat padaperawat. Kaji pendapat perawat

tentang keuntungan

pendokumentasian proseskeperawatan bagi perawat di

rumah sakit atau di puskesmas.

Silahkan diskusikan hal ini....

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SELAMAT BELAJAR