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: – 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 – 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 – 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.lost revenue

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 paper- clipped. You may use binder clips to secure records and tabs or colored paper to separate sections. Physician written order for transport (if non- emergency physician ordered) Any further documentation that supports medical necessity of air and/or ground ambulance transport (i.e. emergency room report)

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 Ambulance (Air or Ground)