scholarly journals Analysis of Nursing Documentation Implementation In Outpatient Room

2020 ◽  
Vol 2 (2) ◽  
pp. 25
Author(s):  
Muhamad Nurudin ◽  
Vivi Yosafianti Pohan ◽  
Tri Hartiti
Keyword(s):  
Medical Record ◽  
Nursing Care ◽  
Initial Assessment ◽  
Nursing Management ◽  
Management Skills ◽  
Nursing Documentation ◽  
Nursing Support ◽  
Service Unit ◽  
Medical Record Documentation

The quality of nursing care is a key element of service quality in hospitals. To realize good quality nursing service and quality in the Outpatient Institution, qualified human resources are also needed and good nursing management skills are needed from a manager or head of the service unit. For the implementation of nursing care documentation in outpatient installations to be carried out optimally, it is necessary to carry out management activities in the form of supervision by carrying out nursing support activities in stages. The purpose of this analysis is to determine the implementation of outpatient nursing medical record documentation. The use of action methods in this analysis aims to develop new skills or new approaches and be applied directly and reviewed the results. From the results of the assessment found several nursing management problems and the priority is the completeness of outpatient nursing medical record documentation which is still low. The action taken is by providing refresher activities or material refreshing on nursing documentation, initial assessment of outpatients, simulations of filling out initial outpatient assessment documentation, making and disseminating supervision forms and techniques for tiered supervision using the supervision form. The activity was attended by 23 participants consisting of the head of the room, the team leader and the nurse executing from the polyclinic or outpatient installation. Evaluation after carrying out activities on the completeness of outpatient nursing medical record documentation was 70%  (14 of 20 samples).

scholarly journals Analysis of The Study of The Supervision of Nursing Room In The Implementation of Nursing Supervision

2020 ◽  
Vol 2 (3) ◽  
pp. 123
Author(s):  
Etik Kustiati ◽  
Vivi Yosafianti Pohan ◽  
Tri Hartiti
Keyword(s):  
Quality Of Service ◽  
Human Resources ◽  
Small Group ◽  
Nursing Care ◽  
Service Needs ◽  
Nursing Management ◽  
Nursing Documentation ◽  
Direct Supervision ◽  
Management Functions

Preparaing rooms for covid 19 patients must be supported by the availability of superior human resources and good nursing management functions. Nursing care given to Covid 19 patients must be complete and well documented. The quality of service needs to be monitored on an ongoing basis by optimizing the supervisory function of the head of the room and the orphans by means of nursing supervision. The purpose of this analysis is to determine the usefulness of the nursing room supervision function in this case by implementing nursing supervision. The use of the action method in this analysis aims to develop new skills or new approaches and be applied directly and studied the results. The assessment using eight nursing management functions carried out in Sulaiman 4 room Roemani Muhammadiyah Semarang Hospital found that the most priority problems were not optimal in the implementation of the supervisory activities of the head of the room and head of the team. The supervision activities in the Sulaiman 4 room have actually been carried out but have not been scheduled and well documented. Actions taken by refreshing the nursing supervision through Small Group Discus activities, preparation of supervision schedules and making supervision formats. Evaluation of the actions taken, SGD was attended by 19 participants consisting of 15 nurses Sulaiman 4 and four other inpatient heads, the supervision schedule was made according to the agreement of the Head of the Room and the Head of the Team. The direct supervision format was used in Sulaiman 4 room according to the predetermined schedule, namely on December 11, 2020. The results achieved from the supervision obtained a significant increase in the number of completeness of nursing documentation from 48.24% to 82.98%.

scholarly journals HUBUNGAN INTENSI DENGAN PERILAKU PERAWAT DALAM PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI INSTALASI GAWAT DARURAT

2018 ◽  
Vol 4 (1) ◽  
Author(s):  
Ardhiles Wahyu Kurniawan
Keyword(s):  
Health Care ◽  
Work Environment ◽  
Nursing Care ◽  
Care Process ◽  
Nursing Documentation ◽  
Exclusion Criteria ◽  
Cross Sectional ◽  
Good Intention ◽  
Care Health

Abstract : The complex IGD work environment will affect the quality of care, health care, including inaccurate or incomplete documentation. Incomplete nursing documentation indicates that the nursing care process is not working properly and continuously. Intentionin documenting can predict the appearance of person behavior including the behavior of nurses, especially in documenting nursing care. The purpose of this study was to analyze correlation intention with nurse behavior in documenting nursing care in Emergency Installation. The research design used correlational analysis with cross sectional approach. The sample in this research is part of nurse of executing at IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan and IGD RS Islam Malang. The sample of 45 nurses IGD and 341 documents were selected according to inclusion and exclusion criteria. The result of statistical analysis of gamma that there is a significant correlation between intention and nursing documentation behavior evidenced by value of p = 0,000, positive correlation direction and strong correlation value is proved by r = 0,739. Hospital and nurse IGD is expected to develop a good intention then formed good nursing documenting behavior as well.Keywords : Nurse IGD, Intention, Nursing Documentation. Abstrak: Lingkungan kerja IGD yang kompleks akan mempengaruhi kualitas perawatan, pelayanan kesehatan, termasuk dokumentasi yang dilakukan tidak tepat atau tidak lengkap. Dokumentasi keperawatan yang tidak lengkap menunjukkan proses asuhan keperawatan tidak berjalan dengan baik dan berkesinambungan. Intensi dalam pendokumentasian dapat memprediksi munculnya perilaku seseorang termasuk perilaku perawat khususnya dalam pendokumentasian asuhan keperawatan. Tujuan penelitian ini untuk menganalis hubungan intensi dengan perilaku perawat dalam pendokumentasian asuhan keperawatan di Instalasi Gawat Darurat. Desain penelitian menggunakan analysis correlationaldengan pendekatan cross sectional. Sampel dalam penelitian ini adalah sebagian perawat pelaksana di IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan Malang dan IGD RS Islam Malang. Sampel berjumlah 45 perawat IGD dan 341 dokumen dipilih sesuai dengan kriteria inklusi dan ekslusi. Hasil analisis statistik uji gammamenunjukkan terdapat hubungan signifikan antara intensi dengan perilaku pendokumentasian keperawatan dibuktikan dengan nilai p = 0,000, arah korelasi positif, dan nilai korelasi kuat dibuktikan dengan nilai r = 0,739. Rumah Sakit dan perawat IGD diharapkan mengembangkan intensi yang baik sehingga diharapkan terbentuk perilaku pendokumentasian keperawatan yang baik pula. Kata Kunci : Perawat IGD, Intensi, Dokumentasi Keperawatan.

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 REKOMENDASI PERAWATAN TERKINI DALAM PENATALAKSANAAN KEJANG PADA NEONATUS

2014 ◽  
Vol 8 (2) ◽  
pp. 70-75
Author(s):  
Elfy Syahreni
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Nursing Care ◽  
Negative Impact ◽  
Central Nervous System Infection ◽  
Clinical Syndrome ◽  
Nursing Management ◽  
High Quality ◽  
Permanent Brain Damage

AbstrakKejang adalah perilaku yang tidak terkontrol yang sering ditemukan pada neonatus. Kejang yang terjadi pada neonatus dapat mengakibatkan kerusakan otak permanen. Penyebab kejang pada neonatus sangat bervariasi di antaranya adalah hypoxic-ischaemic encehepalophaty (HIE), infeksi susunan saraf pusat, perdarahan intrakranial, dan gangguan metabolisme. Pengkajian terhadap tanda dan gejala kejang serta faktor pencetus kejang sangat penting dalam pemberian intervensi keperawatan yang tepat pada neonatus. Dampak lanjut dari kejang pada neonatus dapat menimbulkan kematian dan gejala sisa. Mengingat dampak tersebut, penatalaksanaan perawatan terkini dan berkualitas menjadi bagian penting untuk neonatus penderita kejang. AbstractSeizure is a clinical syndrome characterized by an uncontrolled behavior in neonate. The main cause of seizure in neonate is HIE, central nervous system infection, intracranial hemorrhage, and metabolic disturbance. Seizure will lead to permanent brain damage. Identified sign, symptom and risk factor of seizure are very important in order to provide an accurate nursing management in neonate. Further negative impact of seizure is sequel or death. Considering the facts above, it is necessary to provide the latest nursing care and a high quality of care to neonate who is experiencing seizure.

scholarly journals Kepatuhan Perawat dalam Melakukan Dokumentasi Asuhan Keperawatan

2020 ◽  
Vol 3 (1) ◽  
pp. 17-23
Author(s):  
Ni Kadek Erna ◽  
Ni Luh Putu Thrisna Dewi
Keyword(s):  
Nursing Education ◽  
Nursing Care ◽  
Self Efficacy ◽  
P Value ◽  
Nursing Documentation ◽  
Cross Sectional ◽  
Nursing Services ◽  
Cross Sectional Design ◽  
Spearman Test

Introduction: Nurses' lack of understanding and non-compliance in nursing documentation resulted in low quality of documentation and nursing services. One of factors which affects nursing documentation is self-efficacy. The purpose of this study was to know the correlation of self-efficacy and the compliance of nurses in the nursing documentation. Methods: This research used cross-sectional design with the descriptive documentation approach. The sample of the study was 23 nurses in a hospital recruiting with a nonprobability technique type i.e. total sampling. The inclusion criteria in this study were nurses who were willing to be respondents and had at least a diploma in nursing education. The instrument used was a self-efficacy questionnaire and the nursing care documentation compliance observation sheet. Data analysis used Rank Spearman test with the meaning level 0.05. Results: Most of nurses had high self-efficacy (69.9%) and majority nurse obey in nursing care documentation (73.9%). The statistic test showed p value = 0.000 < (0.05) with r = 0.898. Conclusion: This result confirmed that there is a relation between self-efficacy and the compliance of nurses in nursing documentation at hospital.

scholarly journals Implementation of Documentation of Nursing Care in Wates Hospital

2019 ◽  
Vol 6 (2) ◽  
pp. 68
Author(s):  
Erna Kurniawandari ◽  
Fatma Siti Fatimah
Keyword(s):  
Data Analysis ◽  
Data Collection ◽  
Medical Record ◽  
Frequency Distribution ◽  
Nursing Care ◽  
Medical Records ◽  
Care Process ◽  
Nursing Process ◽  
Nursing Documentation ◽  
Operational Procedure

<p><em>The documentation of nursing care is the important part nurse duty, the best documentation of nursing care process that sees best and have a certain quality should be acurate, complete, and standard. Curently documenting of nursing care in Wates Hospital is practically not yet done according to Standard Operational Procedure. This study aims to know the description of the nursing care of documentation in Inpatient Room of Wates Hospital. This research is descriptive quantitatif which take the sample from inpatient documentation of nursing care in March 2017. The population was about 1106 documents of medical records which the sample obout 111 documents. The technique to take the sample was using cluster random. The research was held on June 2017. The data collection used medical record of patient. The univariat of data analysis used frequency distribution. This research showd that the completeness os documenting of nursing care in assessment aspect (77,5%), diagnosis (93,7%), planning (73,9%), action (45,9%), evaluation (76,6%), nursing care note (45%). The completeness of documentation of nursing care in Inpatient Room of Wates Hospital Kulon Progo is claimed complete (27,9%).</em></p><p> </p><strong>Keywords:</strong> Nursing documentation, nursing process

scholarly journals Medical Record Documentation: The Quality of Physiotherapy Entries

2006 ◽  
Author(s):  
Anna Phillips ◽  
Kathy Stiller ◽  
Marie Williams
Keyword(s):  
Medical Record ◽  
South Australia ◽  
Adelaide Hospital ◽  
Patient Characteristics ◽  
Primary Diagnosis ◽  
Royal Adelaide Hospital ◽  
Physiotherapy Department ◽  
The Impact ◽  
Medical Record Documentation

This study evaluated the standard of in-patient medical record documentation by physiotherapists at the Royal Adelaide Hospital (RAH), Adelaide, South Australia, during 2003. The impact of patient characteristics (ie primary diagnosis and length of stay in hospital) and physiotherapist features (eg employment classification level and years of employment at the RAH) on the standard of documentation was also explored. One hundred medical records were randomly selected for review and 224 physiotherapy entries were audited. The audit tool was based on the RAH Physiotherapy Department Guidelines for Documentation, which was comprised of five sections. Each section contained several items, which were scored as complete, incomplete, absent or not applicable. The total number of completed scores was calculated for each section of the audit form. A standard of 100 per cent completed was expected for the two sections containing those requirements considered mandatory according to the RAH Physiotherapy Department Guidelines, whereas a lower completion rate was considered acceptable for the remaining sections. The standard of documentation varied considerably, with only five items (4.3%) achieving a rate of 100 per cent completion, namely ‘date’, ‘heading physiotherapy’, ‘signature’, ‘page includes patient details’ and ‘after the first attendance’. In total, 94 items (81.7%) were at least 50 per cent completed, which was considered a reasonable overall standard. The patient diagnosis was the only patient or physiotherapist characteristic that significantly affected the standard of documentation (p = 0.03). While the overall standard of documentation was deemed acceptable, it was clear there was room for improvement.

The Effect of Nurses' Leadership Behavior on the Quality of Nursing Care and Patient Outcomes

2020 ◽  
Vol 26 (1) ◽  
pp. e8-e18 ◽  
Author(s):  
Ayse Akbiyik ◽  
Esra Akin Korhan ◽  
Servet Kiray ◽  
Merve Kirsan
Keyword(s):  
Leadership Styles ◽  
Patient Outcomes ◽  
Nursing Care ◽  
Leadership Behaviors ◽  
Leadership Behavior ◽  
Hospital Readmissions ◽  
Nursing Management ◽  
Nursing Leaders ◽  
Quality Of Nursing

ObjectiveThe effect of nursing management styles on patient outcomes and the quality of nursing care (QNC) has recently become a topic of discussion. This review was conducted to examine the effects of leadership styles or behaviors on QNC and on patient outcomes.Methods13 research studies published between 1 January 2010 and 31 May 2016 which conformed to the inclusion criteria were reviewed.ResultsThe effects of nursing leaders' leadership styles or behaviors were examined in studies on patient mortality, QNC from the perspective of nurses, patient satisfaction, unwanted/adverse events, health-care-associated infections, pressure ulcers, falls, unwanted weight loss, hospital readmissions, mismanagement of feeding tubes, and inadequacies in daily nursing care.ConclusionsRelationship-focused leadership behaviors directly or indirectly improved patient outcomes and raised the QNC compared with task-focused leadership behaviors.

scholarly journals The Influence of In-House Training Towards The Accuracy of Nursing Care Documentation

2020 ◽  
Vol 9 (2) ◽  
pp. 523-527
Author(s):  
Sr Felisitas A Sri S ◽  
Emy Sutiyarsih
Keyword(s):  
Nursing Care ◽  
Care Process ◽  
P Value ◽  
Nursing Documentation ◽  
Continuous Training ◽  
Legal Evidence ◽  
Post Test ◽  
Quasi Experimental ◽  
Ongoing Evaluation

Nursing documentation can be used as legal evidence if there are lawsuits. Therefore, nursing documentation must be done systematically and continuously.  The aim of this study was to analyze the effect of in-house training about nursing care documentation to the accuracy of documenting nursing care at X hospital. This study was a quasi-experimental study with one group post-test design. The population of nurses at X hospital. The respondents were nurses that were randomly selected from all wards at X hospital. The ANOVA test was used for data analysis. The results of this study stated that there was a significant influence of in-house training on the accuracy of documentation of nursing care, with p-value = 0.000 < 0.05. In conclusion, the findings highlight that continuous training in nursing care process will be able to improve the quality of nursing care documentation. However, it is recommended to conduct an ongoing evaluation.

scholarly journals A clinical audit report on quality of nursing documentation at Jigme dorji Wangchuck national referral Hospital, 2018

2019 ◽  
Vol 5 (2) ◽  
pp. 15-20
Author(s):  
Kencho Zangmo ◽  
Tshering Dema ◽  
Bhagawat Acharya ◽  
Sonam Sonam ◽  
Tshering Choden ◽  
...  
Keyword(s):  
Nursing Care ◽  
Oral Communication ◽  
Referral Hospital ◽  
Care Process ◽  
Sources Of Information ◽  
Nursing Documentation ◽  
Cross Sectional ◽  
National Referral Hospital ◽  
Quality Of Nursing

Introduction: Whether it is a written documentation or an oral communication, the practice and delivery of healthcare is debated to be critically dependent on effective and efficient communication. Nursing documentation is one of the principal sources of information about patient care and an important tool for communication. This descriptive study assessed both quantitative completeness and quality of nursing documentation by major in-patient units of Jigme Dorji Wangchuck National Referral Hospital. Methods: This cross-sectional study used D-catch tool. Data of randomly selected 317 patient records from six major in-patient units were entered into EpiData file. Using STATA version IC/14, descriptive statistics and multi variable analysis were carried out. Results: Overall quantitative completeness (M-3.4, SD-.59) of the nursing documentation was higher compared to the quality of the documents maintained (M-2.8, SD-.79). The basic and less time-consuming information such as admission data and vital signs charting are documented better compared to the more time consuming and complex documentation such as nursing care process. Conclusion: Systems should not only be in place to enhance documentation quantitatively but also consider uplifting the quality of the documents maintained. Initiating centralized admission system in the hospital may reduce nurses’ burden of clerical documentation, which will allow them to focus on quality nursing documentation and overall nursing care of patients.

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