Pengembangan Format Dokumentasi Asuhan Keperawatan Gawat Darurat Berbasis SDKI, SLKI, dan SIKI
Abstract
This study aims to determine the development of the emergency nursing care documentation format based on the IDHS, SLKI, and SIKI, the quality of the format development, and the quality of the documentation for the development of the design in the Emergency Room of Dradjat Prawiranegara Hospital Serang Banten. The research method is Research and Development. The result of this research is that the nursing diagnosis is determined according to the primary assessment. The quality of developing the emergency nursing care documentation format is functional, efficient, and usable. And the quality of emergency nursing care documentation includes completeness, accuracy, relevance, and good novelty. In conclusion, the format of nursing care documentation based on IDHS, SLKI, SIKI can be used in the emergency room to improve the quality of nursing care.
Keywords: Documentation of Emergency Nursing Care, IDHS, SLKI, SIKI
References
Alvarez, C., Rojas, E., Arias, M., Munoz-Gama, J., Sepúlveda, M., Herskovic, V., & Capurro, D. (2018). Discovering Role Interaction Models in the Emergency Room Using Process Mining. Journal of Biomedical Informatics, 78(June 2017), 60–77. https://doi.org/10.1016/j.jbi.2017.12.015
Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing Care Activities Based on Documentation. BMC Nursing, 18(Suppl 1), 1–5. https://doi.org/10.1186/s12912-019-0352-0
Bond, W. F., Kim, M., Franciskovich, C. M., Weinberg, J. E., Svendsen, J. D., Fehr, L. S., Funk, A., Sawicki, R., & Asche, C. V. (2018). Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs. Journal of Palliative Medicine, 21(4), 489–502. https://doi.org/10.1089/jpm.2017.0566
Frink, M., Lechler, P., Debus, F., & Ruchholtz, S. (2017). Multiple Trauma and Emergency Room Management. Deutsches Arzteblatt International, 114(29-30), 497–503. https://doi.org/10.3238/arztebl.2017.0497
Ioanna, P., Stiliani, K., & Vasiliki, B. (2017). Nursing Documentation and Recording Systems of Nursing Care. Health Science Journal, 9(4), 71–79
Kamil, H., Rachmah, R., & Wardani, E. (2018). What is the Problem with Nursing Documentation? Perspective of Indonesian Nurses. International Journal of Africa Nursing Sciences, 9, 111–114. https://doi.org/10.1016/j.ijans.2018.09.002
Kebede, M., Endris, Y., & Zegeye, D. T. (2017). Nursing Care Documentation Practice: The Unfinished Task of Nursing Care in the University of Gondar Hospital. Informatics for Health and Social Care, 42(3), 290–302. https://doi.org/10.1080/17538157.2016.1252766
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., & Savage, E. (2019). Electronic Nursing Documentation Interventions to Promote or Improve Patient Safety and Quality Care: A Systematic Review. Journal of Nursing Management, 27(3), 491–501. https://doi.org/10.1111/jonm.12727
Permenkes No 47 Thn 2018 tentang Pelayanan Kegawat Daruratan, Pub. L. No. no 47 Thn 2018 (2018)
Pitcher, D., Fritz, Z., Wang, M., & Spiller, J. A. (2017). Emergency Care and Resuscitation Plans. BMJ (Online), 356(February), 1–6. https://doi.org/10.1136/bmj.j876
Platts-Mills, T. F., Richmond, N. L., Lefebvre, E. M., Mangipudi, S. A., Hollowell, A. G., Travers, D., Biese, K., Hanson, L. C., & Volandes, A. E. (2017). Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study. Journal of Palliative Medicine, 20(1), 74–78. https://doi.org/10.1089/jpm.2016.0243
PPNI. (2017). Standar Diagnosis Keperawatan Indonesia (1st ed.). Dewan Pengurus Pusat Persatuan Perawat Nasional Indonesia
PPNI. (2018). Standar Intervensi Keperawatan Indonesia (1st ed.). Dewan Pengurus Pusat Persatuan Perawat Nasional Indonesia
PPNI. (2019). Standar Luaran Keperawatan Indonesia (1st ed.). Dewan Pengurus Pusat Persatuan Perawat Nasional Indonesia
Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2020). Unsafe Nursing Documentation: A Qualitative Content Analysis. Nursing Ethics, 27(5), 1213–1224. https://doi.org/10.1177/0969733019871682
Vafaei, S. M., Manzari, Z. S., Heydari, A., Froutan, R., & Farahani, L. A. (2018). Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran. Open Access Macedonian Journal of Medical Sciences, 6(8), 1527–1532. https://doi.org/10.3889/oamjms.2018.303
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