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