ENGLISH PAPER

Analysis of Nursing Documentation

S1 NURSING STUDY PROGRAM

FACULTY of NURSING
ANDALAS UNIVERSITY
2018
 CHAPTER II
Analysis of Nursing Documentation

2.1 Definition of Nursing documentation

Is the record of nursing care that is planned and delivered to individual clients by qualified nurses or
other caregivers under the direction of a qualified nurse. It contains information in accordance with
the steps of the nursing process. Nursing documentation is the principal clinical information source to
meet legal and professional requirements, Or Nursing documentation is essential for good clinical
communication. Appropriate legible documentation provides an accurate reflection of nursing
assessments, changes in conditions, care provided and pertinent patient information to support the
multidisciplinary team to deliver great care. Documentation provides evidence of care and is an
important professional and medico legal requirement of nursing practice.

2.2 Purpose of Nursing documentation

1. To provide a structured and standardised approach to nursing documentation for inpatients. This
will ensure consistency across the RCH and improve clinical communication
2.Comunication , Is a tool for the health professionals team to communicate the needs and progress
of individual therapy clients resulting from client education conferences and return plans.
3.Legal documentation and practice standards
4.Education
5.Research

2.3 Effectiveness of nursing documentation

Elements of effective documentation are :
Use Common Vocabulary
It’s mean Improves communication and lessens the chance of misunderstanding between
members of the health team .
In the nursing documentation we get : The nursing documentation we get uses a word that is
common and easy to understand by other medical personnel,and the documentation uses
meaning his documentation does not use a particular regional language or language that has a
lot of interpretation and in this documentation using the Indonesian language and language of
health that normally understand.
For example ; nutritional patient are categorized healthy, during the hospital clients get a 3X
daily MBRG diet with a total energy of 1700 calories, Protein, fat, and carbohydrates
Legibilty
It’s mean print if necessary,Don’t erase or obliterate writing,State the reason for the error,sign
and date the correction .
In the nursing documentation we get : There is no erase or obliterate writing and in first paper
there is a date and time when the documentation was made ,And then there is no draw one
line or some line in documentation it indicates that there are no errors in the documentation.

Abbreviations and symbols

It’s mean is a shortened form of a word or phrase. It consists of a group of letters taken from
the word or phrase. For example, the word abbreviation can itself be represented by the
abbreviation abbr., abbrv., or abbrev and the Aims to avoid abbreviations that can be
misunderstood.
In the Nursing Documentation we get :
1. TD : BP (Blood Pressure)
2. S, N, P : TPR (Temperature, Pulse, Respiratory)
3. gr (gram)
4. cc
5. BAB (Elimination)
6. BAK (Elimination)
7. GCS
8. Inj (injection)
9. mg (miligram)
10. tab (tablet)
11. mmol (milimol)
12. dl (desiliter)
13. Hb (hemoglobin)
14. Mmhg (milimeter raksa)
15. Kg (kilogram)

Organization
It’s mean Start every entr with the date and time,Chart in chronological order , include the
person in charge and name of the patient too.
-In the Nursing Documentation we get :there is date and time every medical action taken,
such as laboratory examination on 27-2017
-Written documentation has been arranged neatly or sequentially based on the actions
required for the patient.

-In the documentation there is name of the person in charge of the medical action performed,
and name of the patient.

Accuracy
It’s mean Use factual,descriptive terms to chart exactly what was observed or done,Use
correct spelling and grammar.
In the nursing documentation we get : in documentation the explanation is made based on the
correct vocabulary based on what has been done not fiction or writing and it is proved by the
description of the results in detail against the actions taken and the vocabulary used is easy to
understand.
Documenting a medication Error
It are contains name and dosage of the medication,name of the practitioner who was notified
of the error,tome of notification,Nursing intervention or medical treatment, and client’s
response to treatment .
In the nursing documentation we get :
- in the documentation there is a diagnosis

- There is dosage
- There is nursing intervention

- There is client’s response to treatment

Confidentiality
It’s Mean the nurse is responsible for protecting the privacy and confidentiality of client
interactions,assessments,and care.
In the nursing documentation we get : this is evident when we request the original
documentation from the hospital to require a permit issued from the faculty, if there is no
permit or letter of introduction from the agency concerned then the documentation will not be
given, because this is a private data that is confidential.

Type of documentation
It’s mean The nursing documentation model is a documentation model in which client data is
entered into an appropriate format, records and procedures that can provide a complete and
accurate description of the treatment. In this note it can be clearly known who recorded,
where records were made, how to record, when records were made and needed, and in what
form the notes were made. While nursing documentation techniques is a way of using nursing
documentation into the nursing process.
In the nursing documentation we get :the documentation is POR documentation model , cause
the format is same with the POR type format,and some criteria meet the POR type
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