NURSING CARE ACTIVITIES BASED ON DOCUMENTATION

Background: Nurses engage in various activities from the time of a patient�s admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed. Methods: A quantitative design with a retrospective approach was used, in which 240 medical records from Dr. Kariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records were randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it to be considered. The results were analyzed to compare the standard of care. Results: It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities, according the standard of nursing activities, included the assessment of the functional status of decubitus risk (20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patients� home needs (41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and resume activities nursing (0.8%). Conclusions: Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing activity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality of nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.

1.  UEU-Journal-14461-11_0104.pdf - 380 KB

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• HUBUNGAN PEMBERIAN ASUHAN KEPERAWATAN DAN KECEMASAN KLIEN KANKER PAYUDARA YANG MENJALANI KEMOTERAPI DI RUANG INAP V BEDAH RSPAD GATOT SOEBROTO JAKARTA
• HUBUNGAN MOTIVASI PERAWAT DENGAN PELAKSANAAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUANG RAWAT INAP RUMAH SAKIT PATRIA IKKT
• HUBUNGAN PERAN KETUA TIM DENGAN KINERJA PERAWAT PELAKSANA DALAM PENDOKUMENTASIAN KEPERAWATAN DI UNIT KAMAR OPERASI RS. PURI INDAH JAKARTA
• HUBUNGAN SUPERVISI YANG EFEKTIF DAN KEDISIPLINAN PERAWAT DALAM MELAKUKAN DOKUMENTASI ASUHAN KEPERAWATAN DIRUANG RAWAT INAP 4A DAN 4B DI RS.OMNI ALAM SUTERA TANGERANG
• HUBUNGAN PENDIDIKAN PERAWAT DENGAN MUTU PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUANG RAWAT INAP RUMAH SAKIT IBU DAN ANAK FAMILY
• HUBUNGAN MOTIVASI PERAWAT DAN PELAKSANAAN DOKUMENTASI PENERAPAN ASUHAN KEPERAWATAN DI RUANG RAWAT INAP SILOAM HOSPITALS KEBON JERUK TAHUN 2012
• LAPORAN MAGANG GAMBARAN PERENCANAN TENAGA KEPERAWATAN DI RUMAH SAKIT IBU DAN ANAK SELARAS CIKUPA TANGERANG
• HUBUNGAN MOTIVASI KERJA PERAWAT DENGAN KINERJA PERAWAT DALAM MENGISI KELENGKAPAN DOKUMEN PENGKAJIAN KEPERAWATAN DI RUMAH SAKIT ROYAL PROGRESS SUNTER JAKARTA UTARA
• HUBUNGAN MOTIVASI PERAWAT DENGAN PELAKSANAAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUANG RAWAT INAP RSIA YPK MANDIRI JAKARTA TAHUN 2011
• HUBUNGAN PENGETAHUAN PERAWAT TENTANG ASUHAN KEPERAWATAN DENGAN KELENGKAPAN DOKUMENTASI KEPERAWATAN DI RUMAH SAKIT PANTAI INDAH KAPUK