Nursing

Documentation
1. Nilla Dita Riana NIM : P1337420617003
2. M. Fauzan NIM : P1337420617016
3. M Rois Ilham NIM : P1337420617039
4. Ibi Yulia Setyani NIM : P1337420617032
5. Tania Setyo C NIM : P1337420617067
6. Athallah Muafanudin NIM : P1337420617078
7. Istinganatul Muyassaroh NIM : P1337420617083
 Definition
 Nursing documentation is essential for good clinical
communication. Appropriate legible documentation
provides an accurate reflection of nursing assessments,
changes in conditions, care provided and pertinent patient
information to support the multidisciplinary team to
deliver great care.
 The Purpose
 A written record of the history, treatment, care, and response of the
client while under the care of a health care provider.
 A guide for reimbursement of care costs.
 Evidence of care in a court of law. A legal record that can be used as
evidence of events that occurred or treatments given.
 The Benefit
 LAW
All records of information about
clients are legal and legal documents.
If there is a problem (misconduct)
related to the profession of
keperwatan, and can this as evidence
in court to protect nursing services
(nurses), therefore in entering the
data must be clear both time and date
of implementation.
 SERVICE QUALITY
Data documenting the data must
be complete and accurate, will
provide convenience for parawat in
helping solve client problems and to
know the extent to which halal can be
resolved. this will help improve the
quality / quality of nursing services.
Lanjutan...
 COMMUNICATION
The client state
documentation is a "recorder" tool
for client-related issues. Nurses or
other health professionals can
view the existing documentation
and as a communication tool that
is used as a guide in providing
nursing care.
 FINANCE
Documentation can be
financial value of all nursing care
that has not been, is, and has
been given is fully documented
and can be used as a reference or
consideration in the cost of
nursing for the client.
Lanjutan...
 EDUCATION
Documentation has
educational value, because its
contents concerning chronology of
nursing care activities that can be
used as material or reference of
learning for learners or nursing
profession.
 RESEARCH
Nursing documentation has
research value. The data
contained therein contain
information that can be used as
material or object of research and
development of nursing
profession.
Why Nursing Documentation is
Important?
 because as a legal basis of nursing actions that have been
done if someday there is a demand from the patient.
 To avoid errors in diagnosing.
1. Professional Nursing Documentasion
 Summary Complete and legal documentation provides the nurse with
the story of the hospitalization. The EHR (Electrinic Health Record) is
a communication tool that delineates the hospitalization stay years
after the memory of the patient has faded. Utilization of the care
provision documents created by your institution provides the staff
with the guidance necessary to perform complete and legal
documentation.
 This course has presented key topics related to nursing
documentation, a critical component high quality patient care and
safe, effective nursing practice that is legally and ethically sound.
2.Nursing Documentation in Clinical
Practice
This study shows that training RNs to use a structured documentation system
improved their skills for record keeping and care planning ; however, this is not
sufficient but must be used in combination with a complex of other methods.
Apparently, there are additional factors in the clinical practice that influence the
action of documenting nursing care than lack of knowledge and practice :
 The catching audit instrument proved to be a valid and reliable audit
intrument for nursing documentation in patient records.
 A comprehensive intervention of nursing ducumentation based on the VIPS
model and including organisational support may significantly improve the
quality of nursing documentation in an acute care hospital setting.
3. Nursing Documentation Audit – the Effect
of a VIPS Implementation Programme in
Denmark
 The structured implementation programme significantly improved nursing
documentation, and the simultaneous training of the entire nursing staff
shows promise. The VIPS model has prepared the nurses for more complex
computerized taxonomies and classification systems in the future by
improving the nurses’ analytical skills.
4. An Evaluation of Nursing Documentation of
Acutely Admitted Older Home-living Medical
Patient in a Danish Hospital
 In general, we found low documentation prevalence in the nursing records of
acutely admitted older home-living patients. The prevalence for
documentation of appetite was highest. For all the eight core nursing areas
we found no difference in the prevalence of documentation for patients with
impairment compared to patients without impairment. The results imply that
something else than national guidelines, patient impairments, age, sex, CCI,
and self-rated health of the patient are determining whether documentation
is done or not.
5. Importance and Implementation of
Nursing Documentation : Review Study
 This study was conducted to review the literature about nursing
documentation. We presented the importance and implementation of nursing
documentation. The importance of this topic has been realized here, in
Jordan, and the Ministry of Health has recently started application of
electronic documentation systems. Nursing documentation can be either
paper based or electronic based documentation. Paper based documentation
has been described not meet the required standards. We argued the
standards of nursing documentation that should be met including
completeness, clearing, and concision.
THANK YOU