DOCUMENTATIONBY :

GRUP 101. DEFRY APRILIANDI

(email : defrieodot@yahoo.co.id)2. TITIN ANDRIANA (titinandrianaa@gmail.com)

NURSING ACADEMY OF EAST KOTAWARINGIN

www.akperkotim.ac.id

JALAN BATU BERLIAN NO. 11TELEPHONE : (0531)22960/FAX (0531)22960

THERE IS KNOWING HOW DOCUMENTING IN NURSING

DOCUMENTATIONNursing documentation is a

systematic method to identify the client, plan, implement problem-solving strategies and evaluate the effectiveness of nursing actions that have given (Kozier and ERB)

Solving methods still in nursing care that has been given includes four steps: assessment, planning, implementation and evaluation (Ellis and Nowlis)

BENEFITS OF NURSING DOCUMENTATION1. Preventing neglect and countermeasures

unnecessary.2. Provide flexibility in providing nursing care3. Encourage client participation.4. Give satisfaction to the nurse.5. There is an organized method in nursing

care

DOCUMENTATION PURPOSESAs a means of documentation to help the

implementation of care provided by the team to increase their accuracy and reduce errors and help to achieve the effectiveness and efficiency of time

STANDARD DOCUMENTATIONa. Standard I systematic data

collection on the health status of client data acquired last discussed written / recorded.

b. Standard 2 nursing diagnoses to be obtained from the client's health status data.

c. Standard 3 plan nursing and expected results obtained from nursing diagnoses.

d. Standard 4 nursing media plan including medical approaches to measure the progress of disease acquired in nursing diagnoses.

a) Standard 5 The attitude of nurses to patients is necessary for the healing process.

b) Standard 6 Attitudes treatments help patients to improve the health.

c) Standard 7 Progress and setbacks client's health is determined by the client and the nurse.

d) Standard 8 Progress and setbacks recorded and documented as well as revisions to the plan to the next nursing.

MODEL DOCUMENTATION OF NURSINGTERDIRI DARI 7 KOMPONEN :1. SOR (SOURCE ORIENTED

RECORD)2. POR (PROBLEM ORIENTED

RECORD)3. POR (PROGRESS-ORIENTED

RECORD)4. CBE (CHARTING BY EXEPTION)5. PIE (PROBLEM-INTERVENTION-

EVALUTION)6. POS (PROCESS ORIENTED

SYSTEM)7. SYSTEM DOCUMENTATION CORE

LEGAL ASPECTS OF DOCUMENTATION

1. Common components of data according to the law

2. Guidelines for recording data according to the law

3. Method of recording data4. A situation which gives guidance tendency

in court5. Relations legality ethics in nursing

documentationInsurers answers nursing services through nursing documentation.

THANK YOU