ENGLISH FOR NURSING II

NURSING DOCUMENTATION

GROUP IV
1. FRIMARULY H. DJARANYOERA PO530320119120
2. GRACIA G. BANI PO530320119121

TK. 2 REGULAR A

POLITEKNIK KESEHATAN KEMENKES KUPANG

PRODI DIII KEPERAWATAN
2020
A. WARMER
1. What are they doing ?
 The are currently consulting about the patient’s condition
2. Who is in the bed ?
 Patient
3. Who is standing? What it she doing ?
 Nurse, she is talking to the patient in front of him
4. What is in the screen?
 The results of the dokumentation
B. VOCABULARY SECTION
- Nursing documentation (Dokumentasi Keperawatan)
- Quality care (Perawatan berkualitas)
- Patient records (Catatan pasien)
- Hands on (Tangan diatas)
- Legal documentation (Dokumentasi legal)
- Coworkers (Rekan kerja)
- Chart (Grafik)
- Team effort (Usaha tim)
- Finacial (Keuangan)
- Reinbursement (Pengembalian)
- Third party payer (Pembayar pihak ketiga)
- Scrutinized (Diteliti)
- Potential litigation (Litigasi potensial)
- Lawsuit (Gugatan)
- Medical malpractice (Malpraltik medis)
- Plaintiff attorney (Penggacara penggugat)
- Board of nursing (Dewan keperawatan)
- Abbreviation (Singkatan)
- Subpoenaed for deposition (Di panggil untuk deposisi)
- Witness at trial (Saksi di persidangan)
- Laws and rules (Hukum dan Aturan)
 - Falsified documentation (Dokumentasi yang dipalsukan)
- Sobering experience (Pengalaman yang menenangkan)
- Medication errors (Kesalahan pengobatan)
- Legibly (Dengan terang)
- Shift (Bergeser)
C. READING SECTION
Exercise 1: work in pairs. Read quickly.
 What is the first step in recording good documentation?
Answer:
The first step in recording good documentation is:
Be accurate. For example, do not use vague terms such as “good urine output”.
How many cc’s are “good?” Chart me specific amount and what the urine looks
like.
 What does “write legibly” mean?
Answer:
Write legibly. Medical errors are much more likely to occur if others cannot read
your writing.
D. Writing
In the hospital, it is usually done by nurses or other medical personnel who are
primarily caring for and treating patients, both outpatients and inpatients. But there
are also the duties of health workers that are carried out by them, namely writing
nursing documentation or what is often called nursing care. In nursing
documentation, nurses usually take notes record patient identity, patient examination,
diagnosis, treatment, action, and other services whether performed by doctors or other
health professionals.
Because of these changes, nurses need to develop a new documentation model
that is more efficient and closer to recording and storage. So documentation is very
important for nurses because as a legal basis for nursing actions that have been
carried out if one day there is a patient.