scholarly journals Analisis Sistim Manajemen Dokumentasi Keperawatan pada Poliklinik Gigi Rumah Sakit di Bukittinggi

2015 ◽  
Vol 4 (3) ◽  
Author(s):  
Dewi Rosmalia ◽  
Rizanda Machmud ◽  
Haryadi Mangkuto
Keyword(s):  
Nursing Care ◽  
Nursing Staff ◽  
Analysis Data ◽  
Dental Clinic ◽  
Nursing Documentation ◽  
Documentation System ◽  
Head Nurse ◽  
Clinic Management ◽  
Dynamic Coordination ◽  
Dental Hospital

Abstrak Dokumentasi keperawatan merupakan bukti tertulis pelayanan yang diberikan kepada pasien oleh tenaga keperawatan yang bertujuan untuk menghindari kesalahan, tumpang tindih dan ketidak lengkapan informasi. Dalam asuhan keperawatan agar terbinanya koordinasi yang baik dan dinamis antar tenaga keperawatan serta meningkatkan efisiensi, efektifitas dan menjamin kualitas asuhan keperawatan. Tujuan penelitian ini adalah  menganalisis sistim manajemen dokumentasi keperawatan pada poliklinik gigi rumah sakit berdasarkan standar pelayanan keperawatan. Penelitian dilakukan dengan metode analisis kualitatif, sumber data berasal dari observasi, dokumen dan wawancaramendalam. Informan penelitian berjumlah 10 (sepuluh) orang yang terdiri dari direktur rumah sakit, ketua PPGI Kota Bukittinggi, kepala ruangan poliklinik gigi/ kepala instalasi dan perawat gigi di pol iklinik gigi rumah sakit di Bukittinggi. Validasi data dilakukan dengan triangulasi, selanjutnya dilakukan analisis data, reduksi data, interpretasi dankomunikasikan makna temuan melalui laporan tertulis. Hasil penelitian didapatkan dokumentasi keperawatan pada poliklinik gigi belum terlaksana dengan optimal, hal ini mempengaruhi proses pendokumentasian, tidak tersedianya kartu khusus pencatatan pemeriksaan dan perawatan gigi juga sangat mempengaruhi sistim dokumentasi keperawatan pada poliklinik gigi. Kesimpulan penelitian ini ialahsistim penyelenggaraan dokumentasi keperawatanpada poliklinik gigi belum terlaksana dengan optimal karena belum tersedianya kartu pencatatan pemeriksaan dan perawatan gigi pada poliklinik gigi rumah sakit, belum adanya SOP dokumentasi keperawatan dan jika ada tidak pernah disosialisasikan. Kata kunci: dokumentasi, poliklinik gigi, manajemenAbstract Nursing documentation is written proof of service to patients by nursing staff that aims to avoid errors, and incompleteness of information overlapping in nursing so good and dynamic coordination between nursing staff and improve the efficiency, effectiveness and ensure the quality of nursing care. The objective of this study was to analyze nursing documentation management system in a hospital dental clinic based nursing care standards. The study was conducted with qualitative analysis methods, data sources derived from observations, documents and in-depth interviews. Informants numbered 10 ( ten ) members consisting of the hospital director, chief dental nurses union Indonesia ( PPGI ) of Bukittinggi, the head of the room / installation and head nurse at the dental clinic dental hospital in Bukittinggi. Data validation is done by triangulation, then performed the data analysis, data reduction, data display and conclusion. The results showed nursing documentation in the dental clinic has not done optimally, this affects the process of documenting, recording card unavailability of dental examinations and treatment also greatly affect the nursing documentation system in the dental clinic. In conclusion, the implementation of a nursing documentation system at a dental clinic is not performing optimally due to the unavailability of recording card dental examinations and treatment at the hospital dental clinic, lack of standard operating procedures (SOP) nursing documentation. Keywords: documentation, dental clinic, management

scholarly journals Optimalisasi peran & fungsi manajemen kepala ruangan dalam supervisi dokumentasi asuhan keperawatan di rumah sakit x Jakarta

2021 ◽  
Vol 14 (4) ◽  
pp. 536-544
Author(s):  
Teresa Teresa ◽  
Tuti Afrianti ◽  
Tini Suminarti
Keyword(s):  
Quality Of Care ◽  
Nursing Care ◽  
Health Care Quality ◽  
Descriptive Analysis ◽  
Pilot Project ◽  
Poor Quality ◽  
Care Quality ◽  
Nursing Documentation ◽  
Head Nurse

The role of a head nurse in optimizing of management function in supervision of nursing care documentation at X hospital in JakartaBackground: Nursing documentation is important thing that  is indicator quality of care. Since the nursing documentation is still a poor quality, it requires a supervision by the head nurse.Purpose: The head of nursing is responsible for the direction, organization and strategic planning collaborate with nursing staffs in ensuring the quality of nursing care to achieve accurate, effective and efficient documentation and to complete supervision.Method: A pilot project using questionnaire and observation methods was conducted at difference times on two hospital units in Jakarta.Results: The descriptive analysis results showed that among 18 nurses, 4 nurses believed that nursing documentation is an important, effective and clear way to  ease their job. Hence, supervision is continuity needed to support the improvement of health care quality. The innovative projects will be applied in health care.Conclusion:  Nursing documentation must show continuity and quality of  care nursing under the control and supervision of the head nurse and EMR is used as the instrument for documentation.Keywords :  The role; Head nurse; Management; Supervision; Nursing care; DocumentationPendahuluan: Dokumentasi asuhan keperawatan adalah hal yang penting karena menjadi indikator kualitas perawatan. Penerapan dokumentasi asuhan keperawatan saat ini belum optimal sehingga membutuhkan arahan dan supervisi dari Kepala Ruang/Kepala Unit.Tujuan: Tercapainya supervisi dan keberhasilan pelaksanaan dokumentasi asuhan keperawatan yang komprehensif, berkesinambungan, efektif dan  efisien.Metode: Metode pilot project di salah satu Rumah Sakit di Jakarta dengan pengambilan data melalui  observasi dan kuestioner. Instrumen diujikan pada dua ruangan dalam  waktu yang berbeda.Hasil: Analisis deskripsi pada  sejumlah 18 perawat, 4 orang menyatakan bermanfaat, penting dan mudah dalam penerapannya. Supervisi dilakukan untuk memberikan support terhadap kelangsungan pendokumentasian asuhan keperawatan yang berkesinambungan. Proyek inovasi akan ditindaklanjuti dan diaplikasikan dalam program kerja bidang pelayanan keperawatan.Simpulan: Asuhan keperawatan yang berkualitas memerlukan adanya supervisi. Sarannya penggunaan Instrumen Supervise Dokumentasi Asuhan Keperawatan akan disesuaikan dengan penggunaan pencatatan asuhan keperawatan Elektronic Medical Record/EMR

scholarly journals Analysis of Factors Related to The Documentation of Nursing Care

2020 ◽  
Vol 9 (2) ◽  
pp. 503-514
Author(s):  
Fitra Mayenti ◽  
Yulastri Arif ◽  
Vetty Priscilla
Keyword(s):  
Nursing Care ◽  
Individual Factors ◽  
High Educational Level ◽  
Nursing Documentation ◽  
Head Nurse ◽  
Cross Sectional ◽  
Level Of Education ◽  
Factors Associated ◽  
Long Time ◽  
High Educational

Nursing documentation is written evidence of the implementation of nursing care, but in some hospitals documenting nursing care is still  problem and  far from the Indonesian Ministry of Health, Which is 80%.  This study aimed to determine the factors associated with Nursing documentation of inpatient care at the Ibnu Sina Islamic Hospital Pekanbaru. The design of this study was observational cross sectional. A sample of 82 nurses used a proportional random sampling technique.The results showed that there individual factors 72 % were  early adult nurses, 51,2 % were old nurse with long time, 95,1% were high educational level. Organization factors showed that there 70,7 % were head nurse good category, 75,5% were employee available category, 52, 4% were nursing care good category.There were significant differences of length of work and level of education with documentation of nursing care.

scholarly journals Digital Documentation Platforms in Prehospital Care- Do They Support the Nursing Care

2019 ◽  
Vol 8 (1) ◽  
pp. 84
Author(s):  
Torbjörn Pahlin ◽  
Janet Mattsson
Keyword(s):  
Patient Safety ◽  
Nursing Care ◽  
Technological Development ◽  
Prehospital Care ◽  
Ambulance Service ◽  
Nursing Documentation ◽  
Documentation System ◽  
Transport Organization ◽  
Life Threatening ◽  
Group Interviews

This study examines and describe the ambulance nurse's experience of nursing documentation in single responder and the transfer of the documentation to other care levels.  A qualitative design was used with focus group interviews as data collection method to enhance knowledge of the everyday experience of nursing documentation. The ambulance service in Sweden is a profession in transition that evolved from being a transport organization to provide advanced medical care and nursing. However, all patients do not need advanced medical treatment and the Single responder is an alternative resource to the ambulance that is used when no life-threatening conditions exists. However, the nurse faces a number of challenges when documenting nursing care interventions related to technological development and the mismatch between the care offered and people's demands and needs. Even though nursing care documentation is key to enhance and develop patient safety within a young field as ambulance service. There is a lack of a coherent documentation system and two themes emerged through content analyzes which conveyed how nursing care becomes invisible and how nursing care interventions are communicated through a hidden language. There are serious shortcomings in the transfer of nursing documentation to other care levels as well as deficiencies in the nursing documentation. Which jeopardizes the quality of care and patient safety as well as a systematic development of nursing care in this field.  

scholarly journals Assistência de enfermagem humanizada ao paciente em UTI

2013 ◽  
pp. 17
Author(s):  
Claudir Aparecido Vieira ◽  
Luiz Faustino dos Santos Maia
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Qualitative Analysis ◽  
Continuing Education ◽  
Patient Care ◽  
Nursing Care ◽  
Nursing Staff ◽  
Analysis Data ◽  
Terapia Intensiva ◽  
The Right

Hoje em dia a humanização é ponto de pauta nos encontros nacionais e internacionais da área da saúde. Assim, cada vez mais enfermeiros nas unidades de terapia intensiva tem se preocupado com a sua prática. O presente estudo foi desenvolvido com o objetivo de compreender, reconhecer e entender como o comportamento humanizado reflete ao paciente e identificar a percepção da equipe de enfermagem sobre o processo de humanização. Trata-se de uma pesquisa de revisão bibliográfica descritiva com análise qualitativa, os dados foram coletados nas Bases de Dados de Enfermagem (BDENF) da Biblioteca Virtual de Saúde (BVS) e livros publicados no período de 2009 a 2012. O ambiente de cuidados em UTI precisa ser acolhedor, integrador e estimulador para todos os envolvidos no processo de cuidado e/ou sob o cuidado. A humanização não tem data e nem momento certo para acontecer, devendo estar presente em todas as ações dos profissionais no cuidado ao paciente, a despeito das barreiras encontradas. A educação permanente é uma importante aliada que pode contribuir de forma positiva para assistência humanizada.Descritores: Enfermagem, Humanização, Unidade de Terapia Intensiva. Humanized nursing care to the patient in ICUAbstract: Today, the humanization is point to agenda in national and international meetings in the field of health. Thus, more and more, nurses in intensive care units were been concerned with its practice. The present study was aimed to understand, recognize how the behavior humanized reflects in the patient and identify the perception of the nursing staff on the process of humanization. This is a bibliographic survey with descriptive and qualitative analysis data were collected in the Basis of Data of Nursing (BDENF) of the Virtual Health Library (BVS) and books published between 2009 and 2012. The environment of care in the ICU needs to be welcoming, inclusive and stimulating for all involved in the care and/or under the care. Humanization is undated and not the right time to happen, and should be present in all the actions of the professionals in patient care, despite the barriers encountered. Continuing education is an important tool that can contribute positively to the humanized.Descriptors: Nursing, Humanization, Intensive Care Unit. Asistencia de enfermería humanizada para el paciente en la UCIResumen: Hoy es el orden del día el punto humanización en reuniones nacionales e internacionales en el campo de la salud. Por lo tanto, más y más enfermeras en las unidades de cuidados intensivos se ha preocupado con su practica. El presente estudio tuvo como objetivo comprender, reconocer y entender cómo el comportamiento humanizado refleja el paciente e identificar la percepción del personal de enfermería en el proceso de humanización. Se trata de un estudio de analisis cualitativo descriptivo bibliográfica, se recogieron datos sobre la Base de Datos de Enfermería (BDENF) de la Biblioteca Virtual en Salud (BVS) y los libros publicados entre 2009-2012. El entorno de los cuidados en la UCI debe ser acogedor, integrador y estimulante para todos los involucrados en el cuidado y/o bajo el cuidado. La humanización no tiene fecha y no el momento adecuado para pasar, y debe estar presente en todas las acciones de los profesionales en la atención al paciente, a pesar de los obstáculos encontrados. La educación continua es una herramienta importante que puede contribuir positivamente a humanizado.Descriptores: Enfermería, Humanización, Unidad de Cuidados Intensivos.

scholarly journals Metode Pendokumentasian Elektronik dalam Meningkatkan Kualitas Pelayanan Keperawatan

2018 ◽  
Vol 9 (3) ◽  
pp. 497
Author(s):  
Sulastri Sulastri ◽  
Niken Yuniar Sari
Keyword(s):  
Nursing Care ◽  
Information Exchange ◽  
Nursing Documentation ◽  
Documentation System ◽  
Care Services ◽  
Client Data ◽  
Technological Developments ◽  
Modern Era ◽  
Nursing Processes

Nursing documentation is one of the most important functions for nurses in providing nursing care. The nursing process in the modern era is now a demand from various aspects for nurses. The current development is that nurses must carry out nursing processes based on nursing care standards. The use of electronic nursing documentation can always evolve in line with technological developments, this can increase client life expectancy and reduce errors in intervening with clients. This IT-based documentation system will help in meeting documentation standards, can improve the quality of documentation, facilitate decision making and provide information that is easy to access, can minimize the potential for loss or damage to development records, improve information exchange and coordination between nurses or other health teams, documentation can be easily audited, help improve the accuracy of client data, can access the progress of client health development and reduce maintenance costs so that it can improve the quality of care services.

scholarly journals Development and evaluation of an electronic nursing documentation system

BMC Nursing ◽  
2022 ◽  
Vol 21 (1) ◽  
Author(s):  
Mohsen Shafiee ◽  
Mostafa Shanbehzadeh ◽  
Zeinab Nassari ◽  
Hadi Kazemi-Arpanahi
Keyword(s):  
Literature Review ◽  
Patient Care ◽  
Nursing Care ◽  
Delphi Study ◽  
Methodological Approach ◽  
Care Practice ◽  
Nursing Documentation ◽  
Documentation System ◽  
Data Set ◽  
Care Plans

Abstract Background Nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context. Methods A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of the MDS. Then, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Afterward, the ECNDS was developed according to the finalized MDS, and eventually, its performance was evaluated by involving the end-users. Results The proposed MDS was divided into administrative and clinical sections; including nursing assessment and the nursing diagnosis process. Then, a web-based system with modular and layered architecture was developed based on the derived MDS. Finally, to evaluate the developed system, a survey of 150 registered nurses (RNs) was conducted to identify the positive and negative impacts of the system. Conclusions The developed system is suitable for the documentation of patient care in nursing care plans within a legal, ethical, and professional framework. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.

scholarly journals Development and Evaluation of an Electronic Nursing Documentation System

2021 ◽  
Author(s):  
Mohsen Shafiee ◽  
Mostafa Shanbehzadeh ◽  
Zeinab Nassari ◽  
Hadi Kazemi-Arpanahi
Keyword(s):  
Literature Review ◽  
Patient Care ◽  
Nursing Care ◽  
Delphi Study ◽  
Methodological Approach ◽  
Care Practice ◽  
Nursing Documentation ◽  
Documentation System ◽  
Data Set ◽  
Care Plans

Abstract Introduction: nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reporting is described in scientific literature and care practice, and no uniform structured documentation is given. Aims This study aimed to describe the process of designing and evaluating the content of an electronic nursing documentation system to provide consistent and unified reporting in this context. Methods A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisting of two phases, as follows: A literature review was performed to attain an exhaustive overview of relevant elements of nursing and map the available evidence underpinning the development of the MDS. Second, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Next, the electronic nursing system (ENS) was developed according to the finalized MDS, and finally, its performance was evaluated by involved the end-users. Results The proposed MDS was divided into administrative and clinical sections; including nursing assessment and nursing diagnosis process. Then, a web-based system with modular and layered architecture was designed based on derived MDS. Finally, to evaluate it, a survey by participating 150 registered nurses (RNs) was conducted and the positive impacts and negative impacts of the system were identified. Conclusion The developed system is suitable for the documentation of patient care in nursing care plans. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.

scholarly journals Assistência de enfermagem humanizada ao paciente em UTI

2013 ◽  
Vol 3 (9) ◽  
pp. 17
Author(s):  
Claudir Aparecido Vieira ◽  
Luiz Faustino dos Santos Maia
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Qualitative Analysis ◽  
Continuing Education ◽  
Patient Care ◽  
Nursing Care ◽  
Nursing Staff ◽  
Analysis Data ◽  
Terapia Intensiva ◽  
The Right

Hoje em dia a humanização é ponto de pauta nos encontros nacionais e internacionais da área da saúde. Assim, cada vez mais enfermeiros nas unidades de terapia intensiva tem se preocupado com a sua prática. O presente estudo foi desenvolvido com o objetivo de compreender, reconhecer e entender como o comportamento humanizado reflete ao paciente e identificar a percepção da equipe de enfermagem sobre o processo de humanização. Trata-se de uma pesquisa de revisão bibliográfica descritiva com análise qualitativa, os dados foram coletados nas Bases de Dados de Enfermagem (BDENF) da Biblioteca Virtual de Saúde (BVS) e livros publicados no período de 2009 a 2012. O ambiente de cuidados em UTI precisa ser acolhedor, integrador e estimulador para todos os envolvidos no processo de cuidado e/ou sob o cuidado. A humanização não tem data e nem momento certo para acontecer, devendo estar presente em todas as ações dos profissionais no cuidado ao paciente, a despeito das barreiras encontradas. A educação permanente é uma importante aliada que pode contribuir de forma positiva para assistência humanizada.Descritores: Enfermagem, Humanização, Unidade de Terapia Intensiva. Humanized nursing care to the patient in ICUAbstract: Today, the humanization is point to agenda in national and international meetings in the field of health. Thus, more and more, nurses in intensive care units were been concerned with its practice. The present study was aimed to understand, recognize how the behavior humanized reflects in the patient and identify the perception of the nursing staff on the process of humanization. This is a bibliographic survey with descriptive and qualitative analysis data were collected in the Basis of Data of Nursing (BDENF) of the Virtual Health Library (BVS) and books published between 2009 and 2012. The environment of care in the ICU needs to be welcoming, inclusive and stimulating for all involved in the care and/or under the care. Humanization is undated and not the right time to happen, and should be present in all the actions of the professionals in patient care, despite the barriers encountered. Continuing education is an important tool that can contribute positively to the humanized.Descriptors: Nursing, Humanization, Intensive Care Unit. Asistencia de enfermería humanizada para el paciente en la UCIResumen: Hoy es el orden del día el punto humanización en reuniones nacionales e internacionales en el campo de la salud. Por lo tanto, más y más enfermeras en las unidades de cuidados intensivos se ha preocupado con su practica. El presente estudio tuvo como objetivo comprender, reconocer y entender cómo el comportamiento humanizado refleja el paciente e identificar la percepción del personal de enfermería en el proceso de humanización. Se trata de un estudio de analisis cualitativo descriptivo bibliográfica, se recogieron datos sobre la Base de Datos de Enfermería (BDENF) de la Biblioteca Virtual en Salud (BVS) y los libros publicados entre 2009-2012. El entorno de los cuidados en la UCI debe ser acogedor, integrador y estimulante para todos los involucrados en el cuidado y/o bajo el cuidado. La humanización no tiene fecha y no el momento adecuado para pasar, y debe estar presente en todas las acciones de los profesionales en la atención al paciente, a pesar de los obstáculos encontrados. La educación continua es una herramienta importante que puede contribuir positivamente a humanizado.Descriptores: Enfermería, Humanización, Unidad de Cuidados Intensivos.

scholarly journals EFFECT OF NANDA-I, NIC, AND NOC DOCUMENTATION SYSTEM TRAINING ON QUALITY OF NURSING CARE DOCUMENTATION IN THE PERINATAL WARD OF YOGYAKARTA REGIONAL PUBLIC HOSPITAL

2019 ◽  
Vol 5 (5) ◽  
pp. 180-191
Author(s):  
Enny Eko Setyaningrum ◽  
Intansari Nurjannah ◽  
Anik Rustiyaningsih
Keyword(s):  
Nursing Care ◽  
Public Hospital ◽  
Nursing Intervention ◽  
Control Group ◽  
Nursing Documentation ◽  
Documentation System ◽  
Significant Difference ◽  
Before And After ◽  
Quality Of Nursing

Background: The existing standard of nursing language consists of NANDA-I for diagnostic language standard, Nursing Intervention Classification (NIC) for nursing intervention, and Nursing Outcome Classification (NOC) for nursing outcomes. One way to improve the quality of nursing care documentation is to provide training in the documentation system.Objectives: To determine the effect of providing NANDA-I, NIC, and NOC (NNN) nursing care documentation systems training on the quality of nursing documentation.Methods: This was a pre-experimental study with pretest posttest design without a control group.  Twenty-one nurses and eighty-six Medical Records (MR) of patients who were treated in the perinatal ward of Yogyakarta Regional Public Hospital were used as samples selected using purposive sampling. Those nurses were trained in the nursing care documentation system. The quality of nursing care documentation was measured using modified Quality of Diagnoses, Interventions and Outcomes (Q-DIO) instrument. Data were analyzed using Independent samples t-test with a confidence level of 95%.Results: The average of the scores of the quality of nursing documentation before training was lower (1.91) than the average after training (2.78). There was a significant difference in the quality of nursing documentation before and after training (p < 0.001).Conclusion: Training of NNN nursing documentation system could improve the quality of nursing documentation in the perinatal ward of Yogyakarta Regional Public Hospital.

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