scholarly journals Pendokumentasian Asuhan Keperawatan dalam Pelayanan Keperawatan Jiwa

2019 ◽  
Author(s):  
Satri Andani Zendrato

Latar belakang, Jiwa adalah unsur manusia yang bersifat nonmateri, tetapi fungsi dan manifestasinya sangat terkait pada materi. Mahasiswa yang pertama kali mempelajari ilmu jiwa dan keperawatan jiwa sering mengalami kesulitan dengan hal yang harus dipelajari, karena jiwa bersifat abstrak dan tidak berwujud benda. Tujuan, Untuk memberikan gambaran alasan perawat dalam pelaksanaan pendokumentasi Asuhan Keperawatan dan memberikan gambaran hambatan perawat terhadap pelaksanaan pendokumentasian asuhan. Metode, Kajian ini menggunakan literature review berdasarkan buku teks, buku refrensi, jurnal e-book (10 tahun terakhir) dengan menganalisis, eksplorasi, dan kajian bebas. Hasil, Hasil dari diagnosis gangguan jiwa telah mengalami berbagai penyempurnaan. Pada tahun 1960-an, World Health Organization (WHO) memulai menyusun klasifikasi diagnosis seperti tercantum pada International Classification of Disease (ICD). Klasifikasi ini masih terus disempurnakan, yang saat ini telah sampai pada edisi ke sepuluh (ICD X). Asosiasi dokter psikiatri Amerika juga telah mengembangkan sistem klasifikasi berdasarkan diagnosis dan manual statistik dari gangguan jiwa (Diagnostic and Statistical Manual of Mental Disorder—DSM). Pembahasan, dijelaskan beberapa tentang pendokumentasi terhadap pelayanan keperawatan jiwa yaitu : Alasan Pelaksanaan Pendokumentasian Asuhan Keperawatan, Hambatan pelaksanaan pendokumentasian, Dukungan dalam Pelaksanaan pendokumentasian, Harapan dalam Pelaksanaan Pendokumentasian Asuhan keperawatan.

1991 ◽  
Vol 159 (S14) ◽  
pp. 46-51 ◽  
Author(s):  
Andrew Sims

The psychiatric section, entitled ‘Mental, Behavioural and Developmental Disorders‘ of the International Classification of Diseases, is currently in the process of revision, and ‘ICD—10‘ will shortly become available. This revision will be based partly on its immediate predecessor, the 9th Revision of the International Classification of Diseases (ICD—9; World Health Organization, 1978), and also upon the American Diagnostic and Statistical Manual (DSM—III—R; American Psychiatric Association, 1987). ICD—10 describes and lists symptoms required for making each specific diagnosis and it also refers to inclusions and exclusions. The symptoms themselves, however, are not defined nor described, and an ill-informed method of evaluating symptoms or a lack of thoroughness in their ascertainment will result in mistaken diagnoses. The descriptive psychopathologist clearly has a part to play in encouraging accurate usage.


2017 ◽  
Vol 11 ◽  
pp. 117955651771503 ◽  
Author(s):  
Niels Ove Illum ◽  
Kim Oren Gradel

Aim: To help parents assess disability in their own children using World Health Organization (WHO) International Classification of Functioning, Disability and Health, Child and Youth Version (ICF-CY) code qualifier scoring and to assess the validity and reliability of the data sets obtained. Method: Parents of 162 children with spina bifida, spinal muscular atrophy, muscular disorders, cerebral palsy, visual impairment, hearing impairment, mental disability, or disability following brain tumours performed scoring for 26 body functions qualifiers (b codes) and activities and participation qualifiers (d codes). Scoring was repeated after 6 months. Psychometric and Rasch data analysis was undertaken. Results: The initial and repeated data had Cronbach α of 0.96 and 0.97, respectively. Inter-code correlation was 0.54 (range: 0.23-0.91) and 0.76 (range: 0.20-0.92). The corrected code-total correlations were 0.72 (range: 0.49-0.83) and 0.75 (range: 0.50-0.87). When repeated, the ICF-CY code qualifier scoring showed a correlation R of 0.90. Rasch analysis of the selected ICF-CY code data demonstrated a mean measure of 0.00 and 0.00, respectively. Code qualifier infit mean square (MNSQ) had a mean of 1.01 and 1.00. The mean corresponding outfit MNSQ was 1.05 and 1.01. The ICF-CY code τ thresholds and category measures were continuous when assessed and reassessed by parents. Participating children had a mean of 56 codes scores (range: 26-130) before and a mean of 55.9 scores (range: 25-125) after repeat. Corresponding measures were −1.10 (range: −5.31 to 5.25) and −1.11 (range: −5.42 to 5.36), respectively. Based on measures obtained at the 2 occasions, the correlation coefficient R was 0.84. The child code map showed coherence of ICF-CY codes at each level. There was continuity in covering the range across disabilities. And, first and foremost, the distribution of codes reflexed a true continuity in disability with codes for motor functions activated first, then codes for cognitive functions, and, finally, codes for more complex functions. Conclusions: Parents can assess their own children in a valid and reliable way, and if the WHO ICF-CY second-level code data set is functioning in a clinically sound way, it can be employed as a tool for identifying the severity of disabilities and for monitoring changes in those disabilities over time. The ICF-CY codes selected in this study might be one cornerstone in forming a national or even international generic set of ICF-CY codes for the benefit of children with disabilities, their parents, and caregivers and for the whole community supporting with children with disabilities on a daily and perpetual basis.


Author(s):  
Irina Tyurina

The application of the nomenclature of medical services in the Russian Federation revealed limitations of its structure and content. The analysis of international experience in the classification of medical interventions can help to improve this nomenclature. World Health Organization has prepared a draft of the International Classification of Health Interventions (ICHI), which should be a part of a family of health-related international classifications. It is not yet finished and cannot be used for the classification of medical services on a national level; however, its main principles have already been formulated. All interventions are classified according to three levels (axes): target of intervention; action (the essence of intervention), and means. Lists of types of targets, actions and means have been developed, and recommendations on the classification and coding of medical interventions have been proposed for various situations. There are significant differences in the approach to the classification of medical interventions between ICHI and the Russian nomenclature of medical services. A detailed comparative analysis of the classification principles in ICHI and in the nomenclature is needed.


Sign in / Sign up

Export Citation Format

Share Document