ENGLISH TASK

NURSING DOCUMENTATION ANALYSIS

Created by:

Riski Novita (1711311020)

Intan Delia Puspita (1711311024)

Sri Hartinah (1711312016)

Fadilla Lukvianti (1711312012)

Nofantri Wulantika (1711313042)

Nur Anisa (1711312048)

Dosen Pembimbing:

Ns. Dwi Novrianda S.Kep

NURSING FACULTY

UNIVERSITY OF ANDALAS

2017

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 PREFACE

The writer would like to acknowledge her countless thanks to the Most
Gracious and the Most Merciful, ALLAH SWT who always gives her all the best
of this life and there is no doubt about it. Shalawat and Salaam to the Prophet
Muhammad SAW and his family. This script is presented to fulfill one of the
requirements in accomplishing the S-1 Degree at the Department of Nursing
Faculty in the University of Andalas.

The writer also wish to express her deep and sincere gratitude for those
who have guided in completing this paper.

Padang, February 20th, 2018

The Writer

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 CONTENT LIST

Preface 2

Content list 3

Chapter I 4

Introduction 4

1.1 Background 4
1.2 Formulation Of The Problem 4
1.3 Writing Purpose 4
1.4 The Benefits of Writing 4
1.5 Writing Method 5

Chapter II 6

Analysis 6

2.1 The Definition of Nursing Documentation 6

2.2 Type of The Nursing Documentation 6
2.3 Analysis Nursing Documentation 7

Chapter III 8

3.1 Conclution 8
3.2 Suggestion 8

Reference 9

Attacment 10

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 CHAPTER I

INTRODUCTION

1.1 Background

Nursing documentation is a way to write down all of client’s health

information and the client responses. Nursing documentation is essential for good
clinical comunication. Appropriate legible documentation provides an accurate
reflection of nursing assessment, changes in condition, care provided and
pertinent patient information to support the multidiciplinary team to deliver great
care.

Nursing documentation is very important in nursing proccess. A nursing

documentation taken when the nurses doing and assesment to know about the
client health status. A good skill and ability to comunication greatly will be
usefull to get information to full fill the nursing documentation. But not all of the
nurses can make a good nursing documentation on when they doing their jobs.

1.2 Formulation Of The Problem

After finding a nursing documentation the writers get the problem

formulation to this paper are :

1. what is nursing documentation ?

2. what type of the nursing documentation that you have get?
3. what is your analyses about that nursing documentation?
4 what is your recomendation to improve the nursing documentation in the
hospital that you have analysed?

1.3 Writing Purpose

The writer’s purpose in writing this paper are:
1. To know about nursing documentation
2. To analysed a nuring documentation that the writers found from are hospital
and identification the type of the nursing documetation
3. To give a recomendation to the hospital how to make their nursing
documentation better from the last one.

1.4 The Benefits of Writing

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 The writers want to the readers after reading this paper, it’s will make the
reader have more knowledge about nursing documentation and can understand
how to analyses or make a nursing documentation.

1.5 Writing Method

In writing this paper, the writers collecting the materials from many
resources such as finding in the book and sometimes by searching in the internet.

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 CHAPTER II

ANALYSIS

2.1 The Definition of Nursing Documentation

Nursing documentation is the record of nursing care that is planned and

delivered to individual client’s by qualified nurses or other caregivers under the
direction of a qualified nurse. Nursing documentation is the principle clinical
information source to meet legal and profesional requirements, and one of the
most significant components is nursing care. Quality nursing documentation plays
a vital role in the delivery of quality nursing care services through supporting
better comunication between different care team members to facilitate continuity
of care and safety of the client’s.

2.2 Type of The Nursing Documentation

Based on our observation the type of the nursing documentationin this care
is using problem. Oriented charting (POMR) method. This type is focus on the
client’s subjective and objective data from the client, that of documentating
sistematicty and based the client complaint.

There are three ways to write this method,that are :

1. SOAP (subjective data, objective data, assasment and plan).

2. SOAPIER (SOAP, intervention, evaluation, and revision).

3. PIE (problem-intervention and evaluation).

The adventages of this type are:

1. nursing documentation focus in client health problem and how to solve it.

2. continious in writing the client health status

3. the client health problem served in “checklist” to nursing diagnosis and very
helpfull to remind the nurses to get an attention.

4. the data the nurses need intervented in a nursing planning care

5. uses flow sheet to record routine care.

6. SOAP was developed on a medical model

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 The disadventages of problem oriented charting are :

1. A discharge summary addresses each problem.

2. SOAP entries are usually made at least every 24 hours on any unresolved
problem.

2.3 Analyses Nursing Documentation

After we analysis about the nursing documentation based on the affectivenes

efficiancy and time opproriate we think that :

1. Affectiveness

There are serven elements of effective documentation. We think that the

documentation have write effectivly because almost of the element of effectivenes
documen were of found in the that documentation.

1. the documentation use common vocabulary

2. the documentation write the sistematic and organizing

3. the documentation present the accurate data

4. confidentiality because almost all of the information whict present in

that documentation keep safety by the nurses.

Althrough that documentation almost effective, there are many find of

effectivenes elements does not appear in this documen, such as the documentation
did not use any abbreviation an symbol and it’s very difficult to read.

2. Afficiency

This nursing documentation is very eficien and the information is short but very
usefull

3. Time appropiate

The nursing documentation have writing by the nurse when the client complaint
happen.

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 CHAPTER III

3.1 Conclusion

Nursing documentation is essential for good clinical comunication.

Nursing documentation is very important. Nursing documentatio write down
when the nurses doing nursing proccces. All the type of nursing documentation
have an advantages and disvantages.

3.2 Suggestion

In nursing procces, a good nurse should write down everything about the
client health status in the nuring documentation, because its’s very usefull and
important. And he nurses should make nursing documentation greatly and
effectivly.

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 REFERENCE

Potter & Perry. (2005). Buku Ajar Fundamental Keperawatann : konsep, proses,
dan praktik. Edisi 4. Jakarta : EGC

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