Definition, Benefits and Components of Nursing Documentation
Understanding nursing documentation by Carpenito (1999), is a series of complex and highly diverse and require a fair amount of time in the manufacturing process. Estimated time of documentation of nursing care can reach 35-40 minutes, this is because nurses often make record re ¬ repetitive or duplicative. However, sometimes nursing documentation generated is often less qualified.
Nursing Documentation Standards
While other notions documentation of nursing care according to some experts as follows:
A document or record that contains data about the state of the patient is seen not only from the pain but will also be seen from the type, quality and quantity of services provided nurses to meet patient needs (Ali, 2010).
The series of activities performed by nurses beginning of the process of assessment, diagnosis, plan of action, and evaluation of nursing actions recorded either electronically or manually and can be accounted for by a nurse.
Documentation of nursing care is part of the process of nursing care are carried out systematically by recording the stages of the process of care provided to patients. Documentation of nursing care is an important note made by a nurse either in electronic or manual form of a series of activities undertaken by nurses include five phases: 1) assessment, 2) determination of nursing diagnoses, 3) planning nursing actions, 4) execution / implementation plan nursing, and 5) evaluation of treatment.
The purpose of nursing documentation, among others, the following:
As the media to define the focus of nursing for clients and groups.
To distinguish accountability nurses with other health team members.
As a means to evaluate the actions that have been provided to the client.
As the data required is administratively and legally formal.
Meet legal requirements, accreditation and professional.
To provide useful data in the field of education and research.
Components of nursing care consistent documentation should include the following:
Nursing history consisting of the problems that are happening or expected to happen.
The problems are actual or potential.
Planning and current goals and future.
Testing, treatment and health promotion to help patients achieve a predetermined goal.
Evaluation of nursing goals and modification of the plan of action to achieve the goals set.
Specifically, the scope of the specific documentation of nursing care include:
Preliminary data such as patient identity, perceived grievances.
Nursing history and examination.
Nursing diagnosis set.
Nursing care plan consists of action plans, goal, plan interventions and evaluation of nursing actions.
Education to patients.
Documentation of monitoring parameters and its other nursing interventions.
The development of the result set and expected.
Evaluation planning.
Rationalization of the intervention if needed.
Referral system.
Preparation of the patient home.
While the benefits of nursing documentation according Nursalam (2008), documentation of nursing care according to the following aspects:
Legal aspects: nursing documentation is a legal aspect before the law. Documentation is a record of the evidence given action and as a basis for protecting patients, caregivers and institutions.
Quality of service, communication: Through nursing audit nursing documentation as a tool to measure in comparing the action given by the referenced standards. Thus it can be known whether the work complies with the standards set.
Finance: a good and thorough documentation will be proof that the act of been done by nurses. And with the amount of documentation services provided will be in accordance with the rules set in place, respectively.
Education: nursing documentation can be used as a reference for nursing students.
Research: Research nursing by using secondary data will be very dependent on the quality of nursing documentation made. Error in creating or filling incomplete documentation will make information about the patient's history is blurred.
There are three important components that play a role in making the documentation of nursing care that is:
Means of communication: Good communication between nurses with clients or their families will be obtained so that the information is accurate nursing documentation will be implemented optimally. With good communication will facilitate the process of data collection as well as to create a harmonious relationship between the nurse and client that will assist in solving the problems faced by the client.
Documentation of the nursing process: The nursing process is the core of nursing practice as well as the main content of nursing documentation. Some phases of the nursing process includes several groupings of nursing documentation: a) documentation of nursing assessment, b) documentation of nursing diagnoses, c) nursing planning, documentation of nursing actions, e) evaluation of nursing documentation.
Standard nursing: an overview of the nursing standards of quality, characteristics, traits, and competencies expected of some aspects of the nursing practice. Nursing standards required by nurses as a basis for determining the directions or instructions in the documentation of activities and in making appropriate recording format.
Associated with the models in the documentation of nursing care, according Nursalam (2008), there are several models of the application documentation of nursing care that is often applied in practice, namely: 1) source-oriented records (source oriented record), 2) a record-oriented development / kemaj uan patients (progress oriented record), 3) charting by exception (CBE), 4) Problem Intervention Evaluation (PIE), 5) Process Oriented System (pocus).
In order for the implementation of effective nursing care documentation should pay attention to the following:
Must use the standard terminology that consists of assessment, diagnosis, planning, execution / implementation and final evaluation of the care provided.
Gathering and documenting data obtained in accordance with the circumstances that occurred in patients in a permanent record.
Nursing diagnosis based on data that has been analyzed carefully and accurately.
Documenting observations are accurate, complete, in accordance with the time sequence of events.
Revise the nursing care plan based on the expected results and found the patient
Likewise, the development of nursing care documentation, which have been tested and developed, from the evaluations that have been conducted on the user obtained a good response, nurses become familiar and feel more comfortable working with computer use (Ammenwerth et al., 2003). Studies conducted in Kenya to 107 nurse managers, showed that 98% of nurse managers had a positive attitude towards the use of computers in health care delivery, nurses generally have a positive attitude towards the use of computer systems (Kivuti-Bitok, 2009). Nurses believe that the electronic nursing documentation will be able to improve services and the positive response given to the use of such electronic documentation (De Veer and Francke, 2010).
Referrence, among others;
Ali, Z. , 2010. Fundamentals of Nursing Documentation. EGC. Jakarta
Carpenito, L. J. 1999. Nursing Care Plans & Documentation: Nursing Diagnosis and Collaborative Problems., EGC. Jakarta.
MOH, R.I. 1997.Instrumen Evaluation of the Application of Standards in Hospital Nursing. Jakarta.
Hannah, K. J.et al. , 2009. Standardizing Nursing Information in Canada for Inclusion in Electronic Health Records: C-HOBIC. Journal of the American Medical Informatic Assotiation
Kristiina Häyrinena, J. L., Kaija Saranto. , 2010. Evaluation of electronic nursing documentation-Nursing Terminologies process model and standardized as keys to visible and transparent nursing.
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