DOKUMENTASI KEPERAWATAN pd RUANG KHUSUS

DOKUMENTASI KEPERAWATAN
pd RUANG KHUSUS:
EMERGENCY & CRITICAL CARE
Sri Setiyarini
Subag. Kep.
Gadar
FORMAT PENGKAJIAN PADA
RUANG KHUSUS
Pada ruang khusus seperti ICU UGD,
NICU, kamar operasi, kebidanan dll,
memiiki kekhususan dalam pelayanan
keperawatan & kebutuhan perawatan
pasiennya maka umumnya format
pengkajian pada ruangan tersebut
memiliki spesifikasi data tersendiri
DI RUANG OPERASI, ONE DAY CARE
(ODC), UGD
Pengkajian meliputi
• alasan dirawat
• keadaan yang
menyebabkan masalah
kesehatan sekarang
• berat badan, tinggi
badan, tanda vital,
status kardiorespirasi
• anastesi, reaksi anastesi
• operasi akhir-akhir ini
yang telah dijalani
• terapi yang diberikan untuk
kondisi yang sama
• alergi
• waktu terakhir makan dan
jenis makanan yg masuk
• waktu dan jenis obat yg
dikonsumsi 24 jm terakhir
• gigi palsu, kontaks lens yang
digunakan
• hasil laboratorium
• rontgen thoraks,rontgen
lainnya, dll
ICU
• Documentation in ICU is carried out for a number of
reasons. It ensures continuity of care and provides
up-to-date patient status. It fulfils hospital policies
which furnish the legal aspects of 'duty of care'.
• Bavin (1988: 387) and Fracassi (1987: 66) both argue
that the intensive care nurse has to be highly skilled
today due to technological advances and complex
care of the critically ill patients. Also the
documentation and care required are complex and
time consuming.
flow sheets
• Fracassi (1987) comments, flow sheets are
useful because they increase efficiency, use of
time and enhance legibility and accuracy.
Kleiber and Chase (1989) stated that a flow
chart system saved time, made it easier to find
information and cut down on the number of
forms nurses had to use.
flow sheet in ICU
 involves numerous and separate charts.
 The most common charts in use are:
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Vital signs: respiratory observation
neurological observation
specific observation chart
stool chart
pain chart
nursing management chart
daily fluid balance
progressive fluid balance
problem sheet
ECG collection
biochemistry/haematology
Others used occasionally are
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peritoneal dialysis chart
shunt observation chart
pain relief chart
Swan Ganz chart
intercostal catheter chart
lung function chart
These charts are all used for specific observations or
treatments. They are arranged in bundles on a
clipboard into four groups, observations; fluids;
medications and management.
Follow these rules for charting
chart everything
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include observations,
nursing actions,
patient’s response to therapy and treatment,
any unusual incidents or omitted treatments
safety precautions you took to protect the patient
your attempts to reach the doctor
any reservations you have about a doctor’s orders
the date and time of each entry
the patient’s name and identification number off the chart
your signature on each entry (when in doubt chart
everything)
– leaving blanks or omitting documentation could have
disastrous results in a lawsuit
Emergency Department
Documentation
o Efficient, complete and legible ED nursing
documentation is critical for patient care, legal
protection and proper reimbursement.
o The implications of hurried, incomplete or inaccurate
documentation are significant. Malpractice claims,
EMTALA violations and lost revenue all can result
from poor nursing documentation the Emergency
Department.
Dokumen di Emergency
• Gambaran komprehensif kondisi medis pasien
saat ini dan lalu
• Informasi meliputi:
– Diagnosa masuk
– Diagnosa lain yg dialami terkait terapi
– Inisial assesstment
– Med history
– Pengkajian fisik
– Observasi: tanda vital, dll
– Hasil konsultasi dng bagian
lain
– Alasan masuk/ dirawat dan
dilakukanya terapi
– PROGRAM TERAPI
– Progress note
– Discharge instruction
– dll
Ambulance (Air or Ground)
• Documentation should not be stapled or paperclipped. You may use binder clips to secure records
and tabs or colored paper to separate sections.
• Physician written order for transport (if nonemergency physician ordered)
• Any further documentation that supports medical
necessity of air and/or ground ambulance transport
(i.e. emergency room report)
Ambulance (Air or Ground)
• Trip record Berisi:
– Pernyataan scr detil ttg KONDISI selama di ambulan
ambulance
– Point of origin (identifikasi TEMPAT & ALAMAT dng
lengkap)
– Dokumentasi scr Detail kondisi selama transfer
– Point of destination (nama rumah sakit/tempat yg dituju,
fasilitas, alamat lengkap)
– Jauhnya perjalanan yg ditempuh/biaya per mil/ dll
– Persetujuan dr Pasien jika dirawat/ masuk RS
– Adanya surat keterangan beserta alasanya jika pasien
ditransfer bukan karena kondisi emergensi