You are on page 1of 6





NIM: 15.321.2334



A. Nursing documentation
1. Definition

Nursing documentation according Carpenito (1999), a series of complex and highly

diverse and require considerable time in the manufacturing process. Estimated time of
making the documentation of nursing care can achieve 35-40 minutes, this is because the
nurses often perform recording repeated or duplicative. However, sometimes the nursing
documentation produced is still often lacking in quality.

Nursing Documentation Standards While other notions of nursing care documentation,

according to some experts as follows: A document or record containing data about the
patient's condition is seen not only on the level of pain but also be seen from the type, quality
and quantity of the services they have rendered nurses in meeting the needs of patients (Ali,
The series of activities undertaken by nurses beginning of the process of assessment,
diagnosis, action plans, nursing actions and evaluations are 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 given 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 done by nurses includes five

a) Study
b) determining nursing diagnoses
c) planning of nursing actions
d) execution / implementation plan nursing
e) evaluation of treatment.

Nursing documentation purposes, are as follows: As a medium for defining the focus of
nursing for clients and groups. To distinguish the accountability of nurses and other health
team members. As a means to evaluate the measures that have been provided to clients. As
the data required administrative and legal formal. Meet legal requirements, and professional
accreditation. To provide data that is useful in the field of education and research. Component
documentation consistent nursing care should include the following points: Nursing history is
composed of the problems that are happening or expected to happen. The problems are actual
or potential. Planning and goal at the moment and that will come. Testing, treatment and
health promotion to help patients achieve predetermined objectives. Evaluation of the
objectives of nursing as well as modification of the plan of action to achieve the goals set.
Specifically the scope of nursing care documentation specifically include: Preliminary data of
patients in the form of self-identity, perceived grievances. Nursing history and examination.
The nursing diagnosis is determined. The nursing care plan which consists of an action plan,
objectives, intervention plan 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 process of intervention if needed. The referral

system. Preparation of the patient's home. While the benefits of nursing care documentation
by Nursalam (2008), documentation of nursing care according to the following aspects:

Legal aspects: Nursing documentation created a legal aspect before the law.
Documentation is a proven track record of action is given and as a base to protect patients,
nurses and institutions

Quality of service, communication: Through an audit nursing nursing documentation used

as a tool to measure in comparing the action is given to the referenced standard. Thus it can
be known whether the work in accordance with established standards.

Finance: The documentation is good and thorough will be evidence that tindakah has
been done by nurses. And with this documentation, the amount of services rendered will be
given in accordance with the rules set in place respectively.

Education: Nursing documentation can be used as a reference for students of nursing.

Research: nursing research by using secondary data will be very dependent on the quality
of nursing documentation is created. 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 nursing care
documentation, namely:

Means of communication: Good communication between the nurse with the client or his
family will obtain accurate information so that the nursing documentation will be
implemented optimally. With good communication will facilitate the process of collecting
data and creating a harmonious relationship between the nurse and the client so that it will
help 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 substance of the nursing documentation. Some stages 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) documentation of nursing evaluation.

Standard nursing: nursing standards is a picture of the quality, characteristics, traits, and
competencies expected of some aspects of 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 model in documentation of nursing care, according Nursalam (2008),
there are several models of the application of nursing care documentation that is often applied
in the practice, namely: 1) records were oriented sources (source oriented record), 2) notes
that growth-oriented / kemaj uan patient (progress oriented record), 3) charting by exception
(CBE), 4) Problem Intervention Evaluation (PIE), 5) Process oriented Systems (pocus).

In order for the implementation of effective nursing care documentation should pay attention
to the following:

Must use a standard terminology which consists of assessment, diagnosis, planning,

execution / implementation and final evaluation of the care given.

Collecting and documenting data obtained in accordance with the circumstances that have
occurred in patients in a permanent record.

Nursing diagnosis based on data that has been analyzed carefully and accurately.
Documenting the results of observations are accurate, complete in accordance with the
time sequence of events.

Revise the nursing care plan based on the expected results and were found to patients
Likewise, the development of nursing care documentation, which has been tested and
developed, from evaluations that have been done on the user obtained a good response,
nurses become accustomed and feel more comfortable working with computers
(Ammenwerth et al., 2003). Studies conducted in Kenya to 107 nurse managers, showed that
98% of the nurse managers have 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 with 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).
Hannah, K. al. 2009. Standardizing Nursing Information in Canada for Inclusion in
Electronic Health Record : C-HOBIC. Journal of The American Medical Informatic
Kristiina Häyrinena, J. L., Kaija Saranto. 2010. Evaluation of electronic nursing
documentation—Nursing process model and standardized terminologies as keys to visible
and transparent nursing.