Pelayanan Keperawatan Dokumentasi Keperawatn

7/18/2019 Pelayanan Keperawatan Dokumentasi Keperawatn

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PELAYANAN & DOKUMENTASIKEPERAWATAN

Dr. Elsye Maria Rosa, M.Kep

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The unique function of the nurse is to assist theindividual, sick or well, in the performance of thoseactivities contributing to health, its recovery, or to apeaceful deaththat the client would perform unaided ifhe had the necessary strength, will, or knowledge. Andto do this in such a way as to help the client gainindependence as rapidly as possible.

irginia !enderson"nternational #ouncil of $urses, %&'(

)*+"$"T"$ + $-/"$02


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ROLES AND FUNCTIONS OF THE

NURSE4


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What are Nursing

Services? Nursin Ser!i"es o#er "lien$s, pro!i%ers,an% "ase anaers 'i$( (eal$()rela$e%assessen$ an% "onsul$a$ion in or%er $o

en(an"e $(e %e!elopen$ an%ipleen$a$ion o* $(e "lien$+s plan o*"are.


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What are the Goals ofNursing Services?T(e oal o* nursin ser!i"es is $o (elp proo$e$(e "lien$+s aiu possi-le le!el o*in%epen%en"e an% "on$ri-u$e nursin eper$ise-y per*orin $(e *ollo'in a"$i!i$ies/opre(ensi!e Assessen$ Repor$inE!alua$ion 0/ARE1 re!ie'2Nursin assessen$3reassessen$2Ins$ru"$ion $o "are pro!i%ers an% "lien$s2/are an% (eal$( resour"e "oor%ina$ion2 an%3orE!alua$ion o* (eal$()rela$e% "are nee%sa#e"$in ser!i"e plannin an% %eli!ery.


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ISU STRATEGISISU STRATEGIS12

yuti/2009


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Pelayanan Kepera'a$an Se-aaiSu-sis$e Pelayanan Kese(a$an

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Pelayanan 4epera'a$an erupa4an-aian in$eral %ari sis$e yan4esse"ara 4eseluru(an

Proporsi $enaa 4epera'a$an 0pera'a$%an -i%an1 erupa4an proporsi $enaa$er-esar 05671 Dapa$

epenaru(i 4iner8a rua( sa4i$ %anpus4esas3 sarana pelayanan 4ese(a$an

lainnya


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Peran pera'a$ %ala Usa(a Kese(a$anPerseoranan %an Usa(a Kese(a$anMsyara4a$

Peran pera'a$ %i seua $a$ananpelayanan 4ese(a$an %i se$iap le!el ru8u4an

9en$u4 pelayanan -io)psi4o)sosio)spiri$ualyan 4opre(ensi*

Sasaran 4lien in%i!i%u, 4eluara, 4elopo4,%an asyara4a$

Ren$an se(a$)sa4i$ en"a4up seluru(

proses 4e(i%upan


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:a4e4a$ YANWAT15


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Kon$ri-usi Kepera'a$an16


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Mu$u Pelayanan Kepera'a$an17


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18

G O SERANGA ONSEP


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yuti/200919

FAKTOR EKSTERNALFAKTOR EKSTERNAL( a.l PERUBAHAN SISTEM PEMERINTAHAN,( a.l PERUBAHAN SISTEM PEMERINTAHAN,

GLOBALISASI, KEBIJAKAN, REGULASI, DLLGLOBALISASI, KEBIJAKAN, REGULASI, DLL

PERAWATPERAWAT

KUANTITASKUANTITASKUALITAS/KOMPETNSIKUALITAS/KOMPETNSI

TENAGA KES LAINTENAGA KES LAIN

TARGET PROGRAMTARGET PROGRAM

STANDAR/PEDOMANSTANDAR/PEDOMAN

SARANA,PRASARANA,SARANA,PRASARANA,

PERALATAN KESPERALATAN KES

DANA/PEMBIAYAANDANA/PEMBIAYAAN

KONDISIKONDISI

KERJAKERJA

YANWATYANWAT

PROFESIONALPROFESIONAL

(PERAN,FUNGSI VS(PERAN,FUNGSI VS

TUGAS FAKTUAL)TUGAS FAKTUAL)

INDIKATORINDIKATOR

KINERJAKINERJA

KLINIKKLINIK

JUMLAHJUMLAH

ANGKAANGKAKREDITKREDIT

WATWAT

YANKES/YANKES/

WATWAT

BERMUTUBERMUTU

MONEV, SISTEM INFORMASIMONEV, SISTEM INFORMASI

(UMPAN BALIK)(UMPAN BALIK)

MASYARAKATMASYARAKAT

YAN; MANDIRIYAN; MANDIRI

UNTUKUNTUK

:IDUP SE:AT:IDUP SE:AT

INPUTINPUT PROSESPROSES OUTPUT OUTCOMOUTCOM

ERANGA ONSEPERANGA ONSEP

!ANWAT!ANWAT

REWARD SYSTEM,

JENJANG KARIR


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OPTIMA"ISASI PE"A!ANANEPERAWATAN ME"A"UI PE"A!ANANPRIMA EPERAWATAN20


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21


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Peluan Yan4ep Pria

22

Pagi

Sore

a!a"


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Op$ialisasi PelayananKepera'a$an

9e4er8a sesuai

pera$uranYan pen$in

en(asil4ansesua$u

9e4er8asesuaiuraian3rin"ianpe4er8aan

9er4onsen$rasi pa%apena-a(an nilai un$u4

4epen$inan pasien 9erpi4ir selalu e-eri4an

pelayanan $er-ai4

Selalu -erusa(a eneu4an"ara eper-ai4i proses

4er8a Men%enar4an 4eininan

pasien aar %apa$e-eri4an pelayanan yan%iinin4an

23

Pola #i$ir "a%a Pola Pi$ir &aru


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Keaalan %ala PelayananKepera'a$an Pria24


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KE;IATAN PENIN;KATAN MUTUYANWAT

yuti/2009

25

TU


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KE;IATAN PENIN;KATAN MUTUPELAYANAN KESE:ATAN

yuti/2009

26

SISTEM PEN;EM9AN;AN MANA


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SISTEM PEM&ERIAN PE"A!ANANSISTEM PEM&ERIAN PE"A!ANAN

EPERAWATAN PRO'ESIONA" (SP)P*EPERAWATAN PRO'ESIONA" (SP)P*2#

Apli4asi Nilai)Nilai Pro*esional %ala Pra4$i4Kepera'a$an

Mana8een %an Pe-erian Asu(an Kepera'a$an

Kepeipinan & Mana8een Kepera'a$an Me$o%a Pe-erian Asu(an Kepera'a$an

Ke$enaaan Kepera'a$an

Ke$erapilan Spesi4 Mana8een Asu(an

Kepera'a$an Pene-anan Pro*esional Diri



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DOCUMENTATION


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Tujuan Dokumentasi Keperawatan

menurutPotter (1989)1. Sebagai alat komunikasi anggota tim

2. Sebagai bahan pendidikan bagi perawat

3. Merupakan sumber data dalampenyusunannursing care plan

4. Sebagai audit keperawatan

5. Merupakan dokumen yang legal tindakanasuhan keperawatan

6. Sebagai rujukan untuk bahan penelitian


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Menurut Wraa (2010) prinsip

dokumentasi yang baik harus meliputi:

1.Data kesehatan pasien harus dituliskan secara lengkap,jelas dan tidak menimbulkan keragu-rauan untuk tenagakesehatan lain.

2. Mencantumkan catatan waktu dan tempat tindakandilaksanakan

3. Adanyainform consentuntuk tindakan yang akandilakukan baik itu tindakan medis ataupun tindakankeperawatan.forminform consentini merupakan aspeklegal apabila suatu hal harus dipertanggungjawabkansecara hukum


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Pendokumentasian Keperawatan denganSistem EHR (Electronic Health Record)

Implementasi EHR pada beberapa rumahsakit secara sekaligus merupakan suatu

sistem yang dilakukan untuk efisiensiorganisasi, meningkatkan komunikasiantar RS dan meningkatkan kinerja tim

kesehatan, untuk pelayanan dan kualitasyang lebih baik.


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Dari hasil riset telah dilakukan

didapatkan : Adanya sistem EHR ini dapatmenurunkan angkakejadian pressure ulcer 84% dan pasien jatuhsebesar 61%.

Dokumentasi yang sudah tersistem dengan baikakan lebih memudahkan perawat untukmemonitorkeadaan pasien dan melakukan

intervensi secara adekuat sesuai dengankebutuhan pasien (Dowdinget al, 2011).


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Dokumentasi di Indonesia terdiri

dari:

Format pengkajian

Format standar renpraFormat implementasi

Format catatan perkembangan

Kardeks obatFormat komunikasi perawat-tim kesehatan

Resume pasien


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Methods of Documentation

Narrative Charting

Source-orientedcharting

Problem-orientedcharting

PIE charting

Focus charting

Charting byexception

Computerizeddocumentation

Critical pathways


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Narrative Charting

This traditional method of nursingdocumentation takes the form of a storywritten in paragraphs.

Before the advent of flow sheets, thiswas the only method for documenting

care.


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Source-Oriented Charting

SOR adalah teknik dokumentasi yangdibuat oleh setiap anggota tim

kesehatan.Model ini menempatkan catatan atasdasar disiplin orang atau sumber yang

mengelola pendokumentasian.Dalam melaksanakan tindakan merekatidak tergantung dengan tim lainnya.


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TanggalTanggal Wa$tuWa$tu Su%+erSu%+er Catatan Per$e%+anganCatatan Per$e%+angan

Tanggal,Tanggal,

&ulan,&ulan,

TahunTahun

Wa$tuWa$tu

Tin-a$aTin-a$ann

PP Meli#uti . Peng$a/ian0 I-enti1$asiMeli#uti . Peng$a/ian0 I-enti1$asi

%asalah0 #erlun2a rencana%asalah0 #erlun2a rencanatin-a$an0 rencana segera0tin-a$an0 rencana segera0

intervensi0 #en2elesaianintervensi0 #en2elesaian%asalah0 evaluasi efe$ti1tas%asalah0 evaluasi efe$ti1tastin-a$an -an hasiltin-a$an -an hasil

Tan-a tangan #era3atTan-a tangan #era3at

44 Meli#uti o+servasi $ea-aanMeli#uti o+servasi $ea-aan

#asien0 evaluasi $e%a/uan0#asien0 evaluasi $e%a/uan0

i-enti1$asi %asalah +aru -ani-enti1$asi %asalah +aru -an#en2elesaian lainn2a0 rencana#en2elesaian lainn2a0 rencanatin-a$an -an #engo+atantin-a$an -an #engo+atanter+aruter+aru

Tan-a tangan -o$terTan-a tangan -o$ter

'' Meli#uti hal5hal 2ang #erluMeli#uti hal5hal 2ang #erlu-ila$u$an 1siotera#i0 %asalah-ila$u$an 1siotera#i0 %asalah#asien0 rencana0 intervensi -an#asien0 rencana0 intervensi -anhasilhasil

Tan-a tangan 1siotera#isTan-a tangan 1siotera#is


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Problem-Oriented Charting

Focuses on the clients problem andemploys a structured, logical format

called SOAP charting: S: Subjective data (what the client states) O: Objective data (what is observed/inspected) A: Assessment P: Plan

TanggalTanggal NoNo Masalah lienMasalah lien 4ii-enti1$asi4ii-enti1$asi eterangaeteranga


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TanggalTanggal NoNo Masalah lienMasalah lien 4ii-enti1$asi4ii-enti1$asioleholeh

eterangaeterangann

?33@F?33@F 1A1A

1B1B1C1C

1D1D

22

/GA ena4i-a$4an/GA ena4i-a$4an

(eipleia 4anan %an(eipleia 4anan %an

lea( pa%a sisi 4irilea( pa%a sisi 4iri$u-u($u-u(

..Desi$ pera'a$anDesi$ pera'a$an

%iri 0Ke-ersi(an%iri 0Ke-ersi(an

$u-u(, eliinasi,$u-u(, eliinasi,a4an1a4an1?.?.;anuan o-ili$as;anuan o-ili$as

si4si4=.=.In4on$inensia $o$alIn4on$inensia $o$al5.5.Dis*asia proresi*Dis*asia proresi*..;anuan;anuan

penyesuaianpenyesuaianse(u-unan %enanse(u-unan %enan

s$resor 4e(i%upan %ans$resor 4e(i%upan %an%u4unan sosial yan%u4unan sosial yan

4uran4uran

Dr. Nan%aDr. Nan%as! "i#as! "i#a

s! elas! elas! $etas! $eta

Dr! Al#inDr! Al#in

s! "iwis! "iwi


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4ata -asar4ata -asar 4aftar4aftar

MasalahMasalahRencanaRencana

Tin-a$anTin-a$anCatatanCatatan

Per$e%+anganPer$e%+angan

4ata4ataSu+2e$tifSu+2e$tif

4ata O+2e$tif4ata O+2e$tif

.. ..?.?.

=. %s$=. %s$

S .S .O .O .

A .A .P .P .

4ata4ataSu+2e$tifSu+2e$tif

4ata O+2e$tif4ata O+2e$tif

?.?. ..?.?.

=. %s$=. %s$


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PIE Charting

PROBLEMINTERVENTIONEVALUATION


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PENULISAN PIEPENULISAN PIE

%anggal%anggal WaktuWaktu Catatan PerkembanganCatatan Perkembangan

29/10/200629/10/2006 08000800

12001200! : "D #asien turun 20$30 mm%g #ada! : "D #asien turun 20$30 mm%g #ada

saat berdirisaat berdiri &enge'u( #using #ada&enge'u( #using #ada

saat beruba( #osisisaat beruba( #osisi

P : )isiko *edera ber(ubungan denganP : )isiko *edera ber(ubungan dengan

+aktor interna' / eksterna' ,-i(at+aktor interna' / eksterna' ,-i(at.!.D!.!.D!

I : &enginstruksikan #asien untukI : &enginstruksikan #asien untuk

meminta bantuan bi'a akan turun darimeminta bantuan bi'a akan turun dari

tem#at tidur e' #anggi' di'etakkantem#at tidur e' #anggi' di'etakkan

da'am angkauan #asienda'am angkauan #asien

: Pasien se*ara konsisten meminta : Pasien se*ara konsisten memintabantuan sebe'um turun dari tem#atbantuan sebe'um turun dari tem#at

tidur Pasien masi( merasa #using dantidur Pasien masi( merasa #using dan

menga'ami #eruba(an ortostatikmenga'ami #eruba(an ortostatik


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Focus Charting

A documentation method that uses acolumn format to chart data, action, andresponse (DAR).


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Tg!Tg! a"a" D Da%aD Da%a A A=%io$A A=%io$ R Re)o$)eR Re)o$)e

DS DS Peri/ &aera/Peri/ &aera/

re=%a!re=%a!DO DO A > 3 a!iA > 3 a!iLe"-e ?@Le"-e ?@Le$&ir ?@Le$&ir ?@Dara/ ?@Dara/ ?@

T T 1B1B e$ga+i o!a A !ie$e$ga+i o!a A !ie$2B2B e"o$i%or &aera/ re=%a!e"o$i%or &aera/ re=%a!

&ari iri%a)i&ari iri%a)i3B3B e"o%i'a)i /gie$ee"o%i'a)i /gie$e

er)eora$ga$er)eora$ga$4B4B e$go-)er'a)ie$go-)er'a)i

ere"-a$ga$ U !ie$ere"-a$ga$ U !ie$

P P e$+e!a)a$ a&a !ie$ &a$e$+e!a)a$ a&a !ie$ &a$

e!(arga %e$%a$g ro)e)e!(arga %e$%a$g ro)e)i$e)i -a%eri )-gi$e)i -a%eri )-ge$e-a- &iaree$e-a- &iare

L L

Diag$o)a "e&i) )e)(aiDiag$o)a "e&i) )e)(ai&e$ga$ ro%a !i"a/&e$ga$ ro%a !i"a/,e$a$gB,e$a$gB

) :) :

e'u(an k'ien berkurange'u(an k'ien berkurang

rekuensi ! 2 rekuensi ! 2


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Charting by Exception

Membuat pendokumentasian :catatanpasien lebih nyata, hemat waktu dan

mengakomodasi adanya informasiterbaru.

Model ini dinilai lebih efektif dan efisien

untuk mengurangi adanyaduplikasi danpengulangan dalam memasukkan data.


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Model ini terdiri dari beberapa

elemen inti yaitulembar alur

dokumentasi berdasarkan referensi

standar praktik,protocol dan instruksi incidental


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Computerized Documentation:

Advantages

Decreased

documentation time. Increased legibility andaccuracy.

Clear, decisive, and

concise words.

Statistical analysis of

data. Enhancedimplementation of thenursing process.

Enhanced decisionmaking. Multidisciplinarynetworking.

Tampilanpengkajian


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Tampilan pengkajian


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Tampilan rekomendasi Askep


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Tampilan Renpra


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Tampilan implementasi


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Tampilan Cetak data


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Critical Pathways

A comprehensive, standard plan of carefor specific case situations.

The pathway is monitored to ensure thatinterventions are performed on time andclient outcomes are achieved on time.


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Forms for Recording Data

Kardex

Flow Sheets

Nurses Progress Notes

Discharge Summary

LAMPIRAN 20


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R"&' A"()A* DR! C('%) $A+&K&"&$)

B(DA+ ',RA-A%A

)267&2 P2)!W!"!.

A$A . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! )! R,KA$! $,D(K . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

&$&R . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! R&A+ RA-A% . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

/,(" . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! %+*! $A"&K D(RA-A%. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

',K,R/AA . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! %+*! K,*&AR R" . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

A+A$A . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

A*A$A% . !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

1! $asalah 'erawatan pada saat pasien dirawat .

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

2! %indakan 'erawatan selama dirawat .

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

0! , # a l u a s i .

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

! asehat pada waktu pasien pulang .

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Kepala Ruang Rawat''

!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

(' .


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Kardex

A summary worksheet reference of

basic information that traditionally is notpart of the record. Usually contains: Client data (name, age, marital status, religiouspreference, physician, family contact).

Medical diagnoses: listed by priority. Allergies. Medical orders (diet, IV therapy, etc.). Activities permitted.

K"$4K* $""T ))"P - $*3#

LAMPIRAN 16


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Tanggal

Laborator ium

Pem er iksaan khusus

Kons ul tas i

T indakan / operas i

!" !K

!" !b

# akan / Kalor i

# inum

# obil isasi

Tingg i / !$ ! %

P

&'

&0

('

(0

2'

20

1'

10

)

1& 0

1( 0

12 0

110

10 0

90

80

70

*

&2

&1

&0

(9

(8

(7

(+

('

T

20 0

18 0

1+ 0

1& 0

12 0

10 0

8 0

+ 0

p s s m p s s m p s s m p s s m p s s m p s s m p s s m p s s m p s s m

,b at nama dosis P ernap asan p. , nadi ). * uhu * . Tek anan arah T.

r ek uens i a r a pem ber i an . % 3a t at an ha ri an pem be ri an oba t % bubuhkan tanda pada ko l om yang sesua i sege r a se t e l ah pem ber i an oba t

ia gnosis utama

ia gnosis skund er

Komplikasi %

Peny akit terdahulu

4ek samping

obat te rd ahulu

4ek samp in g obat

yang diurig ai5 ge6a la /

keluhan5 tgl! mula i

pengobatan/tindakan5

kesudaha nnya %

K"$4K* $""T ))"P - $*3#

)o! ok #edik )ama% :mur% th! ;enis% L/P Peker6aan $! Pera


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Flow Sheets

Vertical or horizontal columns for

recording dates and times and relatedassessment and interventioninformation. Also included are notes on:

Client teaching. Use of special equipment. IV Therapy.


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Nurses Progress Notes

Used to document:

Clients condition, problems, and complaints.

Interventions.

Clients response to interventions.

Achievement of outcomes.


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Discharge Summary

Highlights clients illness and course of

care. Includes: Clients status at admission and discharge. Brief summary of clients care. Intervention and education outcomes. Resolved problems and continuing care needs. Client instructions regarding medications, diet,food-drug interactions, activity, treatments, follow-up and other special needs.

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