Upload
mahmasoni-masdar
View
225
Download
0
Embed Size (px)
DESCRIPTION
DOKUMEN adalah Suatu catatan yg dpt dibuktikan atau dijadikan bukti dlm persoalan hukum
Citation preview
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 client’s 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
- Client’s 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 WORKSHEETSto 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 PATHWAYSCare 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 client’s 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 client’s room and include the client
TELEPHONE REPORTS AND ORDERS Report transfers, communicate referrals, obtain client data, solve problems, inform a
physician and/or client’s family members regarding a change in the client’s 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