Nama : Wardatul Ullya

Nim : 2012101010055
Tutorial : 06
Tutor : Ns. Noraliyatun Jannah ,M.Kep

JOURNAL ( TEKNOLOGI YANG DIGUNAKAN DALAM

PERDOKUMENTASIAN)

1. Nursing Recording Systems of the Nursing Care

Documentation There is an important number of recording systems,
and Recording which is used today :
System of Nursig 1. The recording focused on the source
Care 2. The recording focused on the problem
3. The recording model problem-intervention-16,17 evaluation (ΡΙΕ)
4. The focused recording
5. Charting by exception
6. Recording to the computer
7. Case Management

2. Patient-Focused Much effort has been made in the development of nursing

Nursing documentation. Many studies have found inadequate reporting, focused
Documentation more on tasks and treatment than on the patient’s voice. Electronic patient
Expressed by record-systems have been introduced, bringing new challenges because of
Nurses unfamiliarity with computers. Electronic patient records have caused
dissatisfaction and frustration, however, some studies show improvement
in documentation given enough time and effort. Electronic patient record
documentation is an integral part of patient-focused care and thus needs
to be investigated.

3. Evaluation of Documentation is a vital component of all phases of nursing process.

Nursing Documentation is any written or electronically generated information
Documentation about a client that describes the care orservice provided to that client.
on Patient Health records might be paper documents or electronic documents, such
Hygienic Care as elec-tronic medical records, faxes, e-mails, audio or video tapes and
images. Documentation is a professional and legal responsibility of nurses.
Nursing documentation serves for ensuring continuity of care through
communication, for the evaluation of the quality, efficiency and
effectiveness of patient care, and for providing evidence for legal.