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  • Audit Results Pain Management Documentation

    Enviado por

    doni
    26 visualizações12 páginas
    The document summarizes the results of an audit on pain management knowledge from January 2012. It shows that across 13 units (maternity, AE, ICU, etc), a total of 130 nurses were audited and all received blue stickers, meaning 0% received red stickers. The second part of the document outlines indicators that were audited for pain management documentation across different units like L4, 3 lama, ICU and OT. It shows the percentage of documentation compliance for each unit.

    Descrição original:

    Dok Dan Penget Januari 2012

    Título original

    Audit Pain

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    © © All Rights Reserved

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    XLS, PDF, TXT ou leia online no Scribd

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    The document summarizes the results of an audit on pain management knowledge from January 2012. It shows that across 13 units (maternity, AE, ICU, etc), a total of 130 nurses were audited and all received blue stickers, meaning 0% received red stickers. The second part of the document outlines indicators that were audited for pain management documentation across different units like L4, 3 lama, ICU and OT. It shows the percentage of documentation compliance for each unit.

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato XLS, PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    26 visualizações12 páginas

    Audit Results Pain Management Documentation

    Enviado por

    doni
    The document summarizes the results of an audit on pain management knowledge from January 2012. It shows that across 13 units (maternity, AE, ICU, etc), a total of 130 nurses were audited and all received blue stickers, meaning 0% received red stickers. The second part of the document outlines indicators that were audited for pain management documentation across different units like L4, 3 lama, ICU and OT. It shows the percentage of documentation compliance for each unit.

    Direitos autorais:

    © All Rights Reserved
    Baixe no formato XLS, PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 12

    Rekap Hasil Audit Pain Management

    Bulan Januari 2012


    Topik : Audit Knowledge Pain Management

    Stiker
    Perawat Merah Biru
    No Unit
    di audit
    % %
    1 Maternity 5 0 0.00% 5 100.00%
    2 AE 5 0 0.00% 5 100.00%
    3 ICU 5 0 0.00% 5 100.00%
    4 HD 2 0 0.00% 2 100.00%
    5 NICU 2 0 0.00% 2 100.00%
    6 RPK 3 0 0.00% 3 100.00%
    7 L3 8 0 0.00% 8 100.00%
    8 2L 5 0 0.00% 5 100.00%
    9 2B 5 0 0.00% 5 100.00%
    10 L4 3 0 0.00% 3 100.00%
    11 Pediatrik 5 0 0.00% 5 100.00%
    12 OPD 5 0 0.00% 5 100.00%
    13 OT 7 0 0.00% 7 100.00%
    Total 1300.00%
    ement

    Keterangan

    100.00%
    TOOLS AUDIT DOKUMENTASI PAIN MANAGEMENT
    Periode:April 2012
    UNIT :
    Unit
    NO INDIKATOR
    L4 3 lama 3 baru 2 lama 2 baru ICU OT Pediatri RPK Mater NICU TC Keterangan
    1 Pengkajian Px masuk di isi lengkap
    - Form TC : 30
    . Catatan Emergency 3 6 3 5 6 2 2 2 29
    . Form pemindahan pasien rawat jalan 3 5 3 5 7 2 2 2 29
    - Form awal Px masuk 3 6 3 6 9 2 6 2 4 2
    2 setiap shif ada pantauan pain score
    - kelengkapan di form Integrated note (SBAR) 3 6 3 6 9 2 0 2 2
    - kelengkapan form obs khusus pengkajian nyeri: 0
    . Kelengkapan pantauan vital sign 3 6 3 6 9 2 6 2 2
    . Kelengkapan intervensi 30 mnt / 3 jam post pemberian 3 6 3 6 6 2 0 2 2
    analgetik / opioid
    - kelengkapan form obs chart 3 6 3 6 9 2 6 2 4 2
    3 Pencatatan pain score pasien operasi diisi lengkap
    - Form pre operasi 1 2 1 2 2 2 2
    - Form pre anaesthesi 1 2 1 2 2 2 2
    - Form post anaesthesi terisis lengkap 1 2 1 2 2 2 12 2
    - Form post anaesthesi terisis tidak lengkap 0 0 0 0 0 0 1 1
    4 Recovery room:
    - Pantauan 30 menit 1 1 2 1 2 2 2 10 2
    - Pantauan 30 menit II 1 2 1 2 2 2 10 2
    - Pantauan 30 menit III 1 2 1 2 2 2 10 2
    5 Ruang Perawatan Post Operasi :
    - Pantauan 1 jam I 1 2 1 1 1 2 2
    - Pantauan 1 jam II 1 2 1 1 1 2 2
    - Pantauan 1 jam III 1 2 1 1 1 2 2
    - Pantauan 2 jam I x 1 1 1 1 2 2
    - Pantaua 2 jam II x 1 1 1 1 2 2
    - Pantauan 2 jam III x 1 1 1 1 2 2
    - Pantauan 4 jam I 1 2 1 2 1 2 2
    - Pantauan 4 jam II 1 2 1 2 1 2 2
    - Pantauan 4 jam III 1 2 1 2 1 2 2
    - Pantauan 4 jam Iv 1 2 1 2 1 2 2
    - Selanjutnya setiap TTV 1 2 1 2 1 2 6 4
    6 Dicharge planning di resume medis diisi lengkap
    Total V 29 61 33 52 68 39 8 12 18 68 4 45
    Total O 1 4 2 1 7 0 6 0 0 6 16
    Total X 3 3 0 6 0 0 2 0 0 0 0 9
    89% 95% 100% 85% 96% 100% 92% 100% 100% 100% 100% 96%
    % Divisi 96%

    Keterangan : Prosentasi perhitungan: Total Unit %masing2 RM X100%


    Tanda "" menyatakan benar didokumentasi Jumlah X100% RM yag diaudit
    Tanda "" menyatakan tidak diisi / salah indikator
    Rekap Hasil Audit Pain Management

    Bulan Januari 2012


    Topik : Audit Knowledge Pain Management

    Stiker
    Perawat Merah Biru
    No Unit
    di audit
    % %
    1 Maternity 5 0 0.00% 5 100.00%
    2 AE 5 0 0.00% 5 100.00%
    3 ICU 5 0 0.00% 5 100.00%
    4 HD 2 0 0.00% 2 100.00%
    5 NICU 2 0 0.00% 2 100.00%
    6 RPK 3 0 0.00% 3 100.00%
    7 L3 8 0 0.00% 8 100.00%
    8 2L 5 0 0.00% 5 100.00%
    9 2B 5 0 0.00% 5 100.00%
    10 L4 3 0 0.00% 3 100.00%
    11 Pediatrik 5 0 0.00% 5 100.00%
    12 OPD 5 0 0.00% 5 100.00%
    13 OT 7 0 0.00% 7 100.00%
    Total 1300.00%
    ement

    Keterangan

    100.00%
    TOOLS AUDIT DOKUMENTASI PAIN MANAGEMENT
    Periode:April 2012
    UNIT :
    Unit
    NO INDIKATOR
    L4 3 lama 3 baru 2 lama 2 baru ICU OT Pediatri RPK Mater NICU TC Keterangan
    1 Pengkajian Px masuk di isi lengkap
    - Form TC : 30
    . Catatan Emergency 3 6 3 5 6 2 2 2 29
    . Form pemindahan pasien rawat jalan 3 5 3 5 7 2 2 2 29
    - Form awal Px masuk 3 6 3 6 9 2 6 2 4 2
    2 setiap shif ada pantauan pain score
    - kelengkapan di form Integrated note (SBAR) 3 6 3 6 9 2 0 2 2
    - kelengkapan form obs khusus pengkajian nyeri: 0
    . Kelengkapan pantauan vital sign 3 6 3 6 9 2 6 2 2
    . Kelengkapan intervensi 30 mnt / 3 jam post pemberian 3 6 3 6 6 2 0 2 2
    analgetik / opioid
    - kelengkapan form obs chart 3 6 3 6 9 2 6 2 4 2
    3 Pencatatan pain score pasien operasi diisi lengkap
    - Form pre operasi 1 2 1 2 2 2 2
    - Form pre anaesthesi 1 2 1 2 2 2 2
    - Form post anaesthesi terisis lengkap 1 2 1 2 2 2 12 2
    - Form post anaesthesi terisis tidak lengkap 0 0 0 0 0 0 1 1
    4 Recovery room:
    - Pantauan 30 menit 1 1 2 1 2 2 2 10 2
    - Pantauan 30 menit II 1 2 1 2 2 2 10 2
    - Pantauan 30 menit III 1 2 1 2 2 2 10 2
    5 Ruang Perawatan Post Operasi :
    - Pantauan 1 jam I 1 2 1 1 1 2 2
    - Pantauan 1 jam II 1 2 1 1 1 2 2
    - Pantauan 1 jam III 1 2 1 1 1 2 2
    - Pantauan 2 jam I x 1 1 1 1 2 2
    - Pantaua 2 jam II x 1 1 1 1 2 2
    - Pantauan 2 jam III x 1 1 1 1 2 2
    - Pantauan 4 jam I 1 2 1 2 1 2 2
    - Pantauan 4 jam II 1 2 1 2 1 2 2
    - Pantauan 4 jam III 1 2 1 2 1 2 2
    - Pantauan 4 jam Iv 1 2 1 2 1 2 2
    - Selanjutnya setiap TTV 1 2 1 2 1 2 6 4
    6 Dicharge planning di resume medis diisi lengkap
    Total V 29 61 33 52 68 39 8 12 18 68 4 45
    Total O 1 4 2 1 7 0 6 0 0 6 16
    Total X 3 3 0 6 0 0 2 0 0 0 0 9
    89% 95% 100% 85% 96% 100% 92% 100% 100% 100% 100% 96%
    % Divisi 96%

    Keterangan : Prosentasi perhitungan: Total Unit %masing2 RM X100%


    Tanda "" menyatakan benar didokumentasi Jumlah X100% RM yag diaudit
    Tanda "" menyatakan tidak diisi / salah indikator
    Rekap Hasil Audit Pain Management

    Bulan Januari 2012


    Topik : Audit Knowledge Pain Management

    Stiker
    Perawat Merah Biru
    No Unit
    di audit
    % %
    1 Maternity 5 0 0.00% 5 100.00%
    2 AE 5 0 0.00% 5 100.00%
    3 ICU 5 0 0.00% 5 100.00%
    4 HD 2 0 0.00% 2 100.00%
    5 NICU 2 0 0.00% 2 100.00%
    6 RPK 3 0 0.00% 3 100.00%
    7 L3 8 0 0.00% 8 100.00%
    8 2L 5 0 0.00% 5 100.00%
    9 2B 5 0 0.00% 5 100.00%
    10 L4 3 0 0.00% 3 100.00%
    11 Pediatrik 5 0 0.00% 5 100.00%
    12 OPD 5 0 0.00% 5 100.00%
    13 OT 7 0 0.00% 7 100.00%
    Total 1300.00%
    ement

    Keterangan

    100.00%
    TOOLS AUDIT DOKUMENTASI PAIN MANAGEMENT
    Periode:Maret 2012
    UNIT :
    Unit
    NO INDIKATOR
    L4 3 lama 3 baru 2 lama 2 baru ICU OT Pediatri RPK Mater NICU TC Keterangan
    1 Pengkajian Px masuk di isi lengkap
    - Form TC : 30
    . Catatan Emergency 3 6 3 5 6 2 2 2 29
    . Form pemindahan pasien rawat jalan 3 5 3 5 7 2 2 2 29
    - Form awal Px masuk 3 6 3 6 9 2 6 2 4 2
    2 setiap shif ada pantauan pain score
    - kelengkapan di form Integrated note (SBAR) 3 6 3 6 9 2 0 2 2
    - kelengkapan form obs khusus pengkajian nyeri: 0
    . Kelengkapan pantauan vital sign 3 6 3 6 9 2 6 2 2
    . Kelengkapan intervensi 30 mnt / 3 jam post pemberian 3 6 3 6 6 2 0 2 2
    analgetik / opioid
    - kelengkapan form obs chart 3 6 3 6 9 2 6 2 4 2
    3 Pencatatan pain score pasien operasi diisi lengkap
    - Form pre operasi 1 2 1 2 2 2 2
    - Form pre anaesthesi 1 2 1 2 2 2 2
    - Form post anaesthesi terisis lengkap 1 2 1 2 2 2 12 2
    - Form post anaesthesi terisis tidak lengkap 0 0 0 0 0 0 1 1
    4 Recovery room:
    - Pantauan 30 menit 1 1 2 1 2 2 2 10 2
    - Pantauan 30 menit II 1 2 1 2 2 2 10 2
    - Pantauan 30 menit III 1 2 1 2 2 2 10 2
    5 Ruang Perawatan Post Operasi :
    - Pantauan 1 jam I 1 2 1 1 1 2 2
    - Pantauan 1 jam II 1 2 1 1 1 2 2
    - Pantauan 1 jam III 1 2 1 1 1 2 2
    - Pantauan 2 jam I x 1 1 1 1 2 2
    - Pantaua 2 jam II x 1 1 1 1 2 2
    - Pantauan 2 jam III x 1 1 1 1 2 2
    - Pantauan 4 jam I 1 2 1 2 1 2 2
    - Pantauan 4 jam II 1 2 1 2 1 2 2
    - Pantauan 4 jam III 1 2 1 2 1 2 2
    - Pantauan 4 jam Iv 1 2 1 2 1 2 2
    - Selanjutnya setiap TTV 1 2 1 2 1 2 6 4
    6 Dicharge planning di resume medis diisi lengkap
    Total V 29 61 33 52 68 39 8 12 18 68 4 45
    Total O 1 4 2 1 7 0 6 0 0 6 16
    Total X 3 3 0 6 0 0 2 0 0 0 0 9
    89% 95% 100% 85% 96% 100% 92% 100% 100% 100% 100% 96%
    % Divisi 96%

    Keterangan : Prosentasi perhitungan: Total Unit %masing2 RM X100%


    Tanda "" menyatakan benar didokumentasi Jumlah X100% RM yag diaudit
    Tanda "" menyatakan tidak diisi / salah indikator
    Rekap Hasil Audit Pain Management

    Bulan Januari 2012


    Topik : Audit Knowledge Pain Management

    Stiker
    Perawat Merah Biru
    No Unit
    di audit
    % %
    1 Maternity 5 0 0.00% 5 100.00%
    2 AE 5 0 0.00% 5 100.00%
    3 ICU 5 0 0.00% 5 100.00%
    4 HD 2 0 0.00% 2 100.00%
    5 NICU 2 0 0.00% 2 100.00%
    6 RPK 3 0 0.00% 3 100.00%
    7 L3 8 0 0.00% 8 100.00%
    8 2L 5 0 0.00% 5 100.00%
    9 2B 5 0 0.00% 5 100.00%
    10 L4 3 0 0.00% 3 100.00%
    11 Pediatrik 5 0 0.00% 5 100.00%
    12 OPD 5 0 0.00% 5 100.00%
    13 OT 7 0 0.00% 7 100.00%
    Total 1300.00%
    ement

    Keterangan

    100.00%
    TOOLS AUDIT DOKUMENTASI PAIN MANAGEMENT
    Periode:April 2012
    UNIT :
    Unit
    NO INDIKATOR
    L4 3 lama 3 baru 2 lama 2 baru ICU OT Pediatri RPK Mater NICU TC Keterangan
    1 Pengkajian Px masuk di isi lengkap
    - Form TC : 30
    . Catatan Emergency 3 6 3 5 6 2 2 2 29
    . Form pemindahan pasien rawat jalan 3 5 3 5 7 2 2 2 29
    - Form awal Px masuk 3 6 3 6 9 2 6 2 4 2
    2 setiap shif ada pantauan pain score
    - kelengkapan di form Integrated note (SBAR) 3 6 3 6 9 2 0 2 2
    - kelengkapan form obs khusus pengkajian nyeri: 0
    . Kelengkapan pantauan vital sign 3 6 3 6 9 2 6 2 2
    . Kelengkapan intervensi 30 mnt / 3 jam post pemberian 3 6 3 6 6 2 0 2 2
    analgetik / opioid
    - kelengkapan form obs chart 3 6 3 6 9 2 6 2 4 2
    3 Pencatatan pain score pasien operasi diisi lengkap
    - Form pre operasi 1 2 1 2 2 2 2
    - Form pre anaesthesi 1 2 1 2 2 2 2
    - Form post anaesthesi terisis lengkap 1 2 1 2 2 2 12 2
    - Form post anaesthesi terisis tidak lengkap 0 0 0 0 0 0 1 1
    4 Recovery room:
    - Pantauan 30 menit 1 1 2 1 2 2 2 10 2
    - Pantauan 30 menit II 1 2 1 2 2 2 10 2
    - Pantauan 30 menit III 1 2 1 2 2 2 10 2
    5 Ruang Perawatan Post Operasi :
    - Pantauan 1 jam I 1 2 1 1 1 2 2
    - Pantauan 1 jam II 1 2 1 1 1 2 2
    - Pantauan 1 jam III 1 2 1 1 1 2 2
    - Pantauan 2 jam I x 1 1 1 1 2 2
    - Pantaua 2 jam II x 1 1 1 1 2 2
    - Pantauan 2 jam III x 1 1 1 1 2 2
    - Pantauan 4 jam I 1 2 1 2 1 2 2
    - Pantauan 4 jam II 1 2 1 2 1 2 2
    - Pantauan 4 jam III 1 2 1 2 1 2 2
    - Pantauan 4 jam Iv 1 2 1 2 1 2 2
    - Selanjutnya setiap TTV 1 2 1 2 1 2 6 4
    6 Dicharge planning di resume medis diisi lengkap
    Total V 29 61 33 52 68 39 8 12 18 68 4 45
    Total O 1 4 2 1 7 0 6 0 0 6 16
    Total X 3 3 0 6 0 0 2 0 0 0 0 9
    89% 95% 100% 85% 96% 100% 92% 100% 100% 100% 100% 96%
    % Divisi 96%

    Keterangan : Prosentasi perhitungan: Total Unit %masing2 RM X100%


    Tanda "" menyatakan benar didokumentasi Jumlah X100% RM yag diaudit
    Tanda "" menyatakan tidak diisi / salah indikator

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