DOKUMENTASI PROSES KEPERAWATAN

Oleh Ibu Sri Setiyarini

PENGERTIAN
DOKUMEN adalah Suatu catatan yg dpt dibuktikan atau dijadikan bukti dlm
persoalan hukum
WHAT IS DOCUMENTATION
Nightingale described the need for nurses to record "the proper use of
fresh air, light, warmth, cleanliness, & the proper selection &
administration of diet".
In Nightingale's time, documentation was a way to communicate
implementation of MD orders & not a means to observe or assess the
patient's status, as it is today
DOCUMENTATION AS COMMUNICATION
Documentation is defined as written evidence of:
The interactions between and among health professionals, clients,
their families, and health care organizations
The administration of tests, procedures, treatments, and client
education
The results or clients response to these diagnostic tests and
interventionsNurses rely on charting, records, and systems that
support the implementation of the nursing process.
Systematic documentation is critical to presenting the care
administered by nurses in a logical fashion
Critical thinking skills, judgments, and evaluation must be clearly
communicated through proper documentation.
PURPOSES OF HEALTH CARE DOCUMENTATION
Professional Responsibility & Accountability (bernilai hukum)
CARE PLAN
Communication
Education
Research
Quality of care
Peer review
Statistical data
Reimbursment
Legal and Practice Standards
Accrediting & licensing

Akreditasi DEPKES, ISO 2000, Joint commission Indonesia (JCI),

Akreditasi internal RS.

EXAMPLE.. IN US (LEGAL AND PRACTICE STANDARDS)

In 80% to 85% of malpractice lawsuits involving client care, the
medical record is the determining factor in providing proof of
significant events.
Informed Consent
Advance Directives
American Nurses Association (ANA) Standards of Care
State Nurse Practice Acts
Joint Commission on Accreditation of Health Care
Organizations (JCAHO)

PRINCIPLES OF EFFECTIVE NURSING DOCUMENTATION

Nursing notes must be logical, focused, and relevant to care, and
must represent each phase of the nursing process.
based on the nursing process facilitates effective care.

ELEMENTS OF EFFECTIVE DOCUMENTATION

Use of Common Vocabulary
Legibility
Abbreviations and Symbols
Organization
Accuracy
Documenting a Medication Error
Confidentiality

Correcting a documentation error

Documenting a Medication Error

Chart the medication on the MAR.

Document in the nurses progress notes:

-

Name and dosage of the medication

Name of the practitioner who was notified of the error

Time of the notification

Nursing interventions or medical treatment

Clients response to treatment

NURSING PROCESS DOCUMENTATION

Bagian Dari Dokumentasi RS (clinical / medical record)
Metode dipengaruhi oleh kebijakan RS
Perancang dokumen yang terbaik adalah perawat yg
berpengalaman di bidangnya
LEGAL AND PROFESSIONAL ISSUES
Issue legal
Issue profesional
Kerahasiaan
Dokumentasi elektronik
Storage and Disposal of Documentation
Nurses Personal Professional Journal
Access to Records by Clients/Patients
METODE DOKUMENTASI KEPERAWATAN
Narrative Charting
Source oriented record
Problem oriented record (POMR)
PIE Charting
Focus Charting
Charting by Exception (CBE)
Case management Model
Computerized record

FORMAT DOKUMENTASI KEPERAWATAN

 Initial assesstment
Kardex & patient care summary
Flowsheets
Plan of nursing care
Critical collaboration pathway
Progress notes
Discharge & transfer summary
Home health care document
Long term document

OTHER SUPPORTING DOCUMENTATION, INCLUDES BUT IS NOT

RESTRICTED TO:
Policies/Procedures/Protocols
Rosters
Incident Reports
Performance Appraisals/Assessments
Personnel Files
Computer Generated Data
Dependency Studies
Research Data
Documents required for health funding purposes

1. SOURCE-ORIENTED RECORD (CATATAN BERORIENTASI SUMBER)

Masing2 disiplin ilmu (prw, dokter) memilik dokumen sendiri2
Masih banyak di anut saat ini
Lima komponen / Lembar:
data demografi, instruksi, riwayat medik/penyakit, catatan perawat,
catatan laporan khusus

2. Problem oriented record (POMR) Catatan Berorientasi Pd Masalah

Dokumentasi disusun bdrs masalah klien
Mengintegrasikan semua data ttg msl ps yg dikumpulkan oleh
dokter,perawat, dll.

Tiap masalah disusun perencanaan dan perkembangna

masing2

3. PROGRESS-ORIENTED RECORD
Catatan Berorientasi Pada Perkembangan / Kemajuan
Ada 3 jenis catatan pkembangan
Catatan perawat
Flowsheet
Ctt pulang atau ringkasan rujukan
Dipakai di jenis doc no. 1 & 2

4. CHARTING BY EXCEPTION (CBE)

Merup sist. Dok. Yg hanya mencatat scr naratif hasil / penemuan
yg menyimpang dari Normal / standard
Keuntungan: waktu sedikit, fokus data penting, mudah cari data
penting, pencatatan langsung ketika melakukan askep,

pengkajian standar, komunikasi meningkat, mudah melacak

respon, lebih murah.
Mengintegrasi dr 3 komponen:
Flowsheet
Dok. Bdsr standard praktek kep.
Form diletakan di t4 tdr Ps

5. KARDEKS & RENCANA ASKEP

Serangkaian kartu yg disimpan pd index file yg dpt dng mudah
dipindahkan yg berisikan informasi yg diperlukan untuk ASKEP
setiap hari
Meliputi: data demografi dsr, DX medis utama, Instruksi DR
terakhir yg hrs dilaks prw, rencana askep tertulis, instruksi
keperawatan, jadwal pemeriksaan dan prosedur tind tindakan
pencegahan pd askep, hal2 terkait daily living

6. KOMPUTERISASI
Isu-isu terkait dokumentasi yang terkomputerisasi.
Who will have access to the records
How corrections will be made
Who will make corrections in records
Under what circumstances will corrections be made
What mechanism/s prevent erasure of all or part of the record
How entries will be identified

7. NURSES WORKSHEETS
to organize the care they provide, and to manage their time and
multiple priorities.

8. MONITORING STRIPS
(e.g., cardiac, fetal or thermal monitoring; blood pressure
testing) provide important assessment data and are included as
part of the permanent health record

9.CARE MAPS & CLINICAL PATHWAYS

Care maps and clinical pathways outline what care will be done
and what outcomes are expected over a specified time frame for a
usual client within a case type or grouping. Nurses individualize
care maps and clinical pathways to meet clients specific needs
(e.g., by making changes to items that are not appropriate). If the
status of clients varies from that outlined on the care map or

clinical pathway at a particular time period, the variance is

documented, including the reasons and action plan to address it.

TRENDS IN DOCUMENTATION
Standardized data bases are required to ensure accuracy and
precision in nursing information systems.

Nursing Minimum Data Set (NMDS)

Nursing Diagnoses (Taxonomy II)

Nursing Intervention Classification (NIC)

Nursing Outcomes Classification (NOC)

SKILLS USED IN DOCUMENTATION

Cognitive
Technical
Interpersonal
Ethical/Legal
REPORTING

Verbal communication of data regarding the clients health status,

needs, treatments, outcomes, and responses

Summary of current critical information to facilitate clinical

decision making and continuity of client care

Reporting is based on the nursing process, standards of care, and

legal and ethical principles.

Reports require participation from everyone present.

Summary Reports

Walking Rounds

Telephone Reports and Orders

Incident Reports

SUMMARY REPORTS
Commonly occur at change of shift (or when client is transferred).
Assessment data
Primary medical and nursing diagnoses
Recent changes in condition, adjustments in plan of care,
and progress toward expected outcomes
Client or family complaints
WALKING ROUNDS

Nursing, physician, interdisciplinary

Occur in the clients room and include the client

TELEPHONE REPORTS AND ORDERS

Report transfers, communicate referrals, obtain client data, solve
problems, inform a physician and/or clients family members
regarding a change in the clients condition.
Telephone orders are documented in the nurses progress notes
and the physician order sheet.

INCIDENT REPORTS
Used to document any unusual occurrence or accident in the
delivery of client care.

The incident report is not part of the medical record, but it may
be used later in litigation.

SUMMARY

Documentation
Written
Legal record
Uses nursing process
Reporting
Oral
Written
Computer-based
Conferring
Consultations
Referrals
Nursing care conference
Nursing care rounds