MANAGEMENT IN NURSING REPORT

IN C1 WARD RSPAL dr. RAMELAN SURABAYA

Lecturer: Mrs. Made Indra Ayu Astarini, S.Kep., Ns., M.Kep.

Written by:

Tika Dinari Delliyanti 9103019011

Anggi Windi Aulia 9103019025
Aprina Aloysia G. M 9103019003
Maria Aini Matondang 9103091035
Dominic Andryano C. 9103018013

FACULTY OF NURSING
WIDYA MANDALA SURABAYA CATHOLIC UNIVERSITY
SURABAYA
2022
 APPROVAL SHEET

Management Assessment Report in C1 Ward General Hospital Naval Center dr.

Ramelan Surabaya has been approved for presentation on May 20, 2022.
 PREFACE

Thank God for His grace, Our group be able to complete and finished the nursing
management practice report in Room C1 RSPAL dr. Ramelan Surabaya. This report is
carried out for completing the Nursing in Management Practicum course. We recognize that
without the help and guidance of various parties this report will not be completed.
Our hope is that this report can increase knowledge and experience for readers, in
the future it can improve the shape and increase the content of the report to be even better.
Despite all that, we realized that there are still shortcomings both in terms of
sentence arrangement and grammar. We therefore expect constructive criticism and
suggestions for the betterment of this report.

Surabaya, May 20, 2022

Writer

Group 1

CHAPTER 1

1.1 Background
The hospital is an integral part of a social and health organization with the function
of providing complete (comprehensive), disease healing (curative) and disease prevention
(preventive) services to the community. The hospital is also a training center for health
workers and a center for medical research. Health services in hospitals run synergistically
between health and non-health professional disciplines.
Nursing services are an integral part of health services. In health services, the
presence of nurses is a key position, as evidenced by the fact that 40-60% of hospital
services are nursing services and almost all health promotion and disease prevention
services both in hospitals and other health care settings are carried out by nurses.
 Nursing as a professional service is humanistic in nature, uses a holistic approach, is
carried out based on nursing knowledge and tips, is oriented to the client's objective
needs, refers to professional nursing standards and uses nursing ethics as the main guide.
Professional nursing in general is the responsibility of a nurse who always serves humans
and humanity, so they are required to always carry out nursing care correctly (rationally)
and well (ethically).
The contribution of nursing services to health services, which are carried out in
health facilities, is very dependent on the management of care services. Nursing service
management is a process of change or transformation of the resources owned to achieve
goals. Management is a dynamic and proactive approach in carrying out an activity in the
organization. Where in the management includes activities of coordination and
supervision of staff, facilities and infrastructure in achieving organizational goals.
Nursing management is a professional nursing service where the nursing team is
managed by carrying out four management functions, including planning, organizing,
motivating, and controlling. The four functions are interconnected and require technical
skills, human relations, conceptual skills that support quality, efficient and effective
nursing care for the community. This shows that nursing management needs to be given
top priority in the development of nursing in the future, because it is related to
professional and global demands that every development and change requires professional
management by paying attention to any changes that occur.
The characteristics of good quality nursing care include: meeting established
professional standards, resources for nursing care services are used fairly, efficiently, and
effectively, safe for patients and nursing staff, satisfying for patients and nursing staff as
well as social, economic aspects , culture, religion, ethics and community values are
considered and respected. This can be achieved with good management.
Nursing care is the central point of nursing services, quality nursing care can only
be achieved by professional nursing care management. The model of providing nursing
care is one approach in the management of professional nursing care that ensures the
realization of continuity in the delivery of nursing care and accountability.
Room C1 RSPAL dr. Ramelan Surabaya in the management of professional nursing
care applies a model of providing nursing care with the TIM method, through coordinated
and cooperative group work, the provision of comprehensive comprehensive nursing care
for patients can be realized.
Nurses as an integral part of health services, are required to have strong managerial
skills, so that the services provided are able to satisfy the needs of clients. In order to
improve the managerial skills of nursing students, apart from getting nursing management
materials, they also practice directly in the field. Students of the Undergraduate Program,
Nursing Study Program at Widya Mandala Catholic University Surabaya practice to
fulfill the Nursing Management clinical practice assessment in Room C1 RSPAL dr.
Ramelan Surabaya with the direction of clinical supervisors and academic supervisors.
1. Leadership Style
From the results of observations and interviews conducted by the group with
Karu, the type of leadership possessed by the head of the room and the two team
leaders is situational. The delegation of each task is carried out directly by Karu and
Katim when there are actions that must be taken. Every decision or action is discussed
when nurses meet with each other in the room at that time.
Like if there is Karu on a shift, then the one who leads the discussion if there is
something that needs to be discussed. And if there is no Karu on the shift, then Katim
will lead the discussion.
2. Role and function
a. Head of Room
1) Leading the weigh-in during the morning shift.
2) Supervise the documentation in the SIM RS.
3) Supervise and control nursing service activities in the C1 ward.
4) Plan the number and categories of nursing staff and other personnel as needed.
5) Plan the number of types of maintenance equipment needed as needed.
6) Plan and determine the type of activity or nursing care that will be held
according to the patient's needs.
7) Organize and coordinate all activities of the nursing room service.
8) Compile and organize a list of nursing staff and other personnel according to
the needs and applicable regulations or regulations.
9) Carry out an orientation program for new nursing staff or other personnel who
will work in the nursing room.
10) Provide direction and motivation to nursing staff to carry out nursing care
according to provisions or standards.
11) Coordinate all existing activities by collaborating with various parties involved
in services in the inpatient room.
12) Responsible for the implementation of the equipment inventory.
13) Accompany doctors during visits to examine patients and record treatment
programs, as well as inform staff to implement them.
14) Maintain the patient's feelings to feel safe and protected during the
implementation of care services.
15) Maintain the feeling of officers to feel safe and protected during the
implementation of care services.
b. Team Leader
1) Make plans based on the duties and authorities delegated by the head of the
room.
2) Make assignments, supervise and evaluate the performance of team
members/implementers.
3) Know the patient's condition and can assess the patient's needs.
4) Develop the ability of team members / implementers.
5) Follow the handover of patients from the previous shift with the head of the
room.
6) Develop a nursing care plan.
7) Prepare requirements for the implementation of nursing care.
8) Provide immediate assistance to patients with emergency problems.
9) Orienting new patients.
10) Perform reporting and documentation.
11) Together with the head of the room, make details of tasks for team members /
implementers in accordance with the planning for patients who are their
responsibility in providing nursing care.
12) Perform functional division of team members/executors.
13) Coordinate work with other health teams.
14) Arranging time off for team members/implementation.
15) Delegating the task of implementing the nursing process to team
members/implementers.
16) Perform reporting and documentation.
17) Provide direction on the duties of each team member / implementer.
18) Provide information to team members / implementers related to nursing care.
19) Repair, overcome weaknesses or obstacles that occur at the same time
Evaluate the performance and reports of team members / implementers
c. Implementing Nurse
1) Carry out the handover of every change of service which includes patients and
equipment.
2) Do patient askep.
3) Prepare, maintain, store tools so that they are ready for use.
4) Planning nursing interventions to solve problems and make steps / ways to
solve problems
5) Carry out nursing actions according to plan.
6) Carry out rotational service according to the schedule that has been made by
the head of the room.
7) Maintain the environment for smooth service.
8) Carry out an orientation program to patients about health agencies and their
environment, applicable rules and regulations, as well as existing facilities and
their use.
9) Creating good cooperative relationships with patients and their families as well
as with members of the health team.
10) Help refer patients to other health workers who are more capable of solving
manageable health problems.
11) Preparing patients who will be discharged, including:
- Provide forms for administrative completion, for example: permission to
go home, sick certificate, diet instructions, prescription medication if
necessary, referral letter/re-examination, and certificate of full payment.
12) Provide health education to patients and families in accordance with the
patient's circumstances and needs, for example regarding diet, the importance
of re-examination in hospitals or other health agencies.
13) Obey the rules that have been set at the hospital where he works.
 3. Organizational structure

Kepala
Ruangan

Ketua Ketua
Tim 1 Tim 2

PP 1 PP 2 PP 3 PP 4 PP 5 PP 6 PP 7 PP 8 PP 9 PP 10 PP 11 PP 12 PP 13 PP 14 PP 15 PP 16 PP 17

Information:
Name Functional Position Name Functional Position
Novi Indriyatie R., S.Kep., Ns. PK III Karu Pramiarti, Amd.Kep. PK III Katim 2
Aniek Supriyati, Amd.Kep. PK III Katim 1 P9 Atika Riski P., Amd.Kep. PK II PP
P1 Dwi Malindawati, Amd.Kep. PK III PP P10 Sriani, S.Kep., Ns. PK II PP
P2 Novita Kurnia, Amd.Kep. PK II PP P11 Sundari, Amd.Kep. PK I PP
P3 Edwin Wiranata, Amd.Kep. PK II PP P12 Fery Setiawan, Amd.Kep. PK I PP
P4 Eka Nurundah F., Amd.Kep. PK II PP P13 Yuniara Dwi P., S.Kep., Ns. PK I PP
P5 Titik Hariyati, Amd.Kep. PK I PP P14 Novita Primasari, Amd.Kep. PK I PP
P6 Amartha Nurmala S., S.Kep., Ns. Pre PK PP P15 Ika Fitri Anggraeni, Amd.Kep. Pre PK PP
P7 Firman Shah, S.Kep., Ns. Pre PK PP P16 Luthfiah Widya R., Amd.Kep. Pre PK PP
P8 Kholis'atun Nisa, S.Kep., Ns. Pre PK PP P17 Feby Arbityas Putri, S.Kep., Ns. Pre PK PP
4. Nursing Care Model
From the results of observations and interviews, the MAKP used in room C1 is
the team model MAKP. Where there is a Room Head, two Team Leaders and several
members on each team. In the division of the two teams, they are responsible for
several rooms, for team 1 in rooms 1, 2 and 3, while for team 2 in rooms 4 and 5. The
selection of Team Leaders is based on experience, years of service, abilities and
education. For Team Leaders 1 and 2 usually enter the morning shift, while shifts for
team members usually adjust.
From the observation, it was also found that the implementation of nursing
care was carried out functionally. An implementing nurse will perform the same
actions for rooms 1 to 5 and another implementing nurse will perform different
actions for rooms 1 to 5.
5. Bed Occupancy Ratio (BOR) and Patient Dependency
 Patient 11 May 2022 as of 21.00 : 17 patients
17
BOR= ×100 %
22
BOR=77,3 %
 Patient 12 May 2022 as of 21.00 : 20 patients
20
BOR= ×100 %
22
BOR=90,9 %
 Patient dependency level (15 May 2022)
Patients Qualification Source Needs
Addiction Level Numbe Morning Afternoon Evening
r of
Patient
s
Minimum 3 3 x 0.17 = 0.51 3 x 0.14 = 0.42 3 x 0.07 = 0.21
Partial 5 5 x 0.27 = 1.35 5 x 0.15 = 0.75 5 x 0.10 = 0.50
Total 5 5 x 0.36 = 1.80 5 x 0.30 = 1.50 5 x 0.20 = 1
13 3.66 2.67 1.71
4 3 2
Total nurses: 9️
78 x 9 / 286 = 2.45
So, the total number of nurses needed is 9 + 2.45 + 2 = 13.45 = 14 people
The total number of nurses in room C1 is 20 people, so, according to Douglass,
the number of nurses is sufficient.
6. Implementation
a. Delegation
 Karu – Katim : Katim accompanies the doctor when Karu is absent, and when
Karu has a meeting the Katim replaces Karu's duties, besides that Karu also
distributes tasks regarding quality improvement to PP.
 Katim – PP : Katim delegates to the implementing nurse to carry out
procedures for wound care and other treatments, and during a meeting, the
implementing nurse accompanies the consul by telephone.
 PP – Student: The implementing nurse will delegate some nursing actions to
students, if the student can do it himself then the implementing nurse will not
accompany while if the student cannot, the implementing nurse will assist.
Sometimes also ask students to be assistants in providing nursing care.
b. Supervision
From the results of interviews, supervision in room C1 is routinely carried
out 1 to 2 times a week. Supervision is carried out in each room to see if there are
problems in each room. whether it has been resolved or not and the following is
the supervision process carried out:
1. Pre-supervision
a. Supervisors (Karu and Katim) determine the activities to be
supervised
b. Supervisor sets goals
2. Implementation of Supervision
a. Supervisor assesses the performance of nurses in carrying out their
duties
b. Supervisors get some things that require coaching.
c. The supervisor calls Katim and PA to conduct coaching and clarify
problems.
d. Implementation of supervision by inspection, interviews, and
validating secondary data, namely supervisors clarify existing
problems and supervisors conduct questions and answers with
nurses

3. Post-Supervision
 a. Supervisor provides supervision assessment
b. Supervisor provides feedback and clarification.
c. Supervisor provides reinforcement and follow-up improvements
c. New Patient Admission
From the results of observations, there are several ways to accept new
patients, namely from admission (usually patients who have been scheduled for
surgery) and also from the ER (usually patients who experience both minor and
severe accidents). From these two routes, the admissions/ IGD officer will contact
room C1 to ask for an empty bed. Patients who enter through the ER will be
escorted to room C1 by the ER staff and accompanied by their families, the ER
officers will convey the information that needs to be conveyed. Meanwhile,
patients who enter through admission will usually come with their families
without being accompanied by officers.
After the patient arrives in room C1 either through admission/IGD, they
will be directed to the room (bed) that will be occupied, and the family is called
to the Nurse Station room. At the nurse station, the nurse conducts an assessment
to the family regarding the patient, also explains the patient's treatment plan,
explains the informed consent and hospital regulations if the patient is to take
action that requires informed consent, then asks if the family understands the
explanation that has been given. If the family understands, the nurse invites the
family to sign. After that the nurse will go to the patient to do TTV and
assessment.
d. Patient Discharge
From the results of observations when the patient was discharged, which
was explained by the nurse, the first was an explanation of care during illness, the
nurse would explain about the disease and treatment that must be done both at
home and control later, then before going home the patient was provided with
how to clean the surgical wound with good and right, then tells how many times
the wound cleaning will be done, and the nurse will remind to keep the surgical
wound clean, then the second explains the therapy that will be carried out by the
patient, progress during treatment, (blood pressure, pulse, temperature , SPO2,
then the results of the consul, then the third, explaining the drugs to be taken as
recommended by the doctor, and informing or explaining the amount eaten by the
 patient in one day,and said the side effects of the drugs being consumed, the third
told the patient to control according to the schedule that had been determined.
Furthermore, the nurse will provide files that will be taken home by the
patient, such as lab results, X-rays, CT scans, MRI/MRA, a sick certificate if
requested by the patient for work/school purposes, then the patient's resume and
return letter. medicines to be taken home by the patient. Later the nurse will
notify that the certificate for patient control is already in the envelope and is
always brought at the time of control. And lastly, the nurse will ask the patient or
family to bring the patient to the emergency room if immediate action is needed,
and finally the patient will be asked to sign the patient's return certificate.
e. Weigh Thank
From the observations, the weigh-in is always preceded by prayer, the one
leading the prayer is the nurse on the previous shift. After that, the nurse who had
previously read out the documentation of the actions that had been taken, usually
if the nurse after her wanted to confirm it would be asked directly not at the end
after the delivery was complete. The weigh-in which was carried out in room C1
already used S communication (patient name, age, medical diagnosis, DPJP), B
(last complaint felt by the patient), A (nursing problems experienced by the
patient) and R (action to be taken on patient). After that, the nurses before and
after will go to the patient rooms for observation. After observation, there are
nurses who perform nursing actions on patients, there are those who clean /
organize the action room.
f. Drug Centralization
From the observations, the centralization of drugs is done by unit dose
dispending (UDD). Pharmacists will distribute drugs according to the prescription
from the doctor to the room. And those who will distribute to patients are
implementing nurses and distributed according to the existing hours.
g. Nursing Round
From the results of the interview, before Covid the nursing round was
usually carried out. However, because the round documentation book was lost
when changing rooms, the nursing round has never been carried out again until
now.
7. Quality Control
a. Patient Satisfaction

8%

Kepuasan Tinggi
Kepuasan Sedang
Kepuasan Rendah

92%

b. Nurse Satisfaction

15%

Kepuasan Tinggi
Kepuasan Sedang
Kepuasan Rendah

85%

c. KTD* :2 reports (01 March – 20 May 2022)

d. KNC* :3 reports (01 March – 20 May 2022)
e. KTC* :-
f. UTI* :0 reports (01 March – 20 May 2022)
g. IDIO* :2 reports (01 March – 20 May 2022)
h. Painful :(not found.) However, based on group observations, many cases of
pain occur because room C1 is the operating room.
i. Phlebitis :11 laporan (01 maret – 20 mei 2022)
j. Risiko jatuh : (not found.)
8. Dana dan Fasilitas
a. Pendanaan
Sumber pendanaan ada beberapa yaitu dari dana mandiri, dana BPJS dan juga
dana keanggotaan tantara.
b. Fasilitas
No Nama Barang Jumlah
.
A. Ruang IA
1. Tempat tidur 4
2. Meja makan pasien 4
3. Tv 1
4. Cermin kaca 2
5. AC 2
6. Kursi 4
7. Lemari pasien 4
8. Bel pasien 4
9. 02 flow meter 4
10. Gantungan handsanitizer 2
11. Botol handsanitizer 2
12. Rak handuk 1
13. Closed duduk 1
14. Closed jongkok 1
15. Gayung 2
16. Lampu 4
17. Standart infus 2
18. Standart infus mobile 3
19. Bantal drakon 4
20. Gorden 6M 4
B. Ruang II
1. Tempat tidur 4
2. Meja makan pasien 4
3. Tv 1
4. Cermin kaca 2
5. AC 2
6. Kursi 4
7. Lemari pasien 4
8. Bel pasien 4
9. 02 flow meter 4
10. Gantungan handsanitizer 2
11. Botol handsanitizer 2
12. Rak handuk 1
13. Closed duduk 1
14. Closed jongkok 1
15. Gayung 2
16. Lampu 4
17. Standart infus 2
18. Standart infus mobile 3
19. Bantal drakon 4
20. Gorden 6M 4
C. Ruangan III
1. Tempat tidur 2
2. Meja makan pasien 2
3. Tv 1
4. Cermin kaca 1
5. AC 1
6. Kursi 2
7. Lemari pasien 2
8. Bel pasien 2
9. 02 flow meter 2
10. Gantungan handsanitizer 1
11. Botol handsanitizer 1
12. Rak handuk 1
13. Closed duduk 1
14. Dispenser 1
15. Gayung 1
16. Lampu 2
17. Standart infus 2
18. Standart infus mobile 1
19. Bantal drakon 2
20. Gorden 6M 2
21. Galon 1
D. Ruangan 4
 1. Tempat tidur 6
2. Meja makan pasien 5
3. Tv 0
4. Cermin kaca 2
5. AC 2
6. Kursi 6
7. Lemari pasien 6
8. Bel pasien 6
9. 02 flow meter 6
10. Gantungan handsanitizer 4
11. Botol handsanitizer 4
12. Rak handuk 1
13. Closed duduk 1
14. Closed jongkok 1
15. Gayung 4
16. Lampu 4
17. Standart infus 2
18. Standart infus mobile 2
19. Bantal drakon 6
20. Gorden 6M 6
E. Ruangan 5
1. Tempat tidur 6
2. Meja makan pasien 5
3. Tv 0
4. Cermin kaca 2
5. AC 2
6. Kursi 6
7. Lemari pasien 6
8. Bel pasien 6
9. 02 flow meter 6
10. Gantungan handsanitizer 4
11. Botol handsanitizer 4
12. Rak handuk 1
13. Closed duduk 1
14. Closed jongkok 1
15. Gayung 4
16. Lampu 4
17. Standart infus 2
18. Standart infus mobile 2
19. Bantal drakon 6
20. Gorden 6M 6
F. Ruang Linen
1. Alamari linen 6
2. Loker perawat 5
3. Cermin kaca 0
4. Gantungan baju 2
5. Baju operasi dewasa 2
6. Baju operasi anak 6
7. Baju atasan piama 6
8. Baju lengan pendek 6
9. Bedong bayi motif 6
10. Celana panjang 4
11. Daster 4
12. Duk lubang 1
13. Duk luka 110x 110 1
14. Guling 1
15. Perlak biasa 4
16. Rel tekuk 9 meter 4
17. Scort operasi 2
18. Sarung 2
19. Selimut putih 6
20. Selimut loreng 6
21. Selimut bayi lorek 0
22. Selimut woll 5
23. Green pillowcase 22
24. TNI AL pillowcase 10
25. bolster 0
26. baby pillow case 0
27. Children's pattern pillowcase 0
28. bed sheet set 0
29. Plain cream sheets 0
30. White sheets or rubber 22
sheets
31. Motive bed sheet 0
32. TNI AL 10
33. Laken sticks 0
34. White cloth sticks 20
35. Green laken stick 0
36. Laken cream sticks 0
37. washcloth 0
38. Patient strap 0
G. prayer room
1. prayer rug 2
2. Mukenah 1
3. Wardrobe 1
H. Warehouse
1. Wheel chair 4
2. Oxygen tube 2
I. Kitchen space
1. Gas stove 1
2. Ice Cupboard 1
3. Regulator 1
4. Dispenser 1
5. washbasin 6
6. Gallon 1
7. cupboard 1
8. Plate 5
9. Spoon 5
10. Gas cylinders 1
J. Sphol Hock
1. Dirty linen 2
2. washbasin 2
3. Medical waste bin 1
4. Non-medical trash 1
5. Bucket 1
6. Laundry detergent 1
7. Linen soaker 1
8. Skpesel 1
9. Closet sitting 1
K. Karu Room
1. Table 1
2. Chair 2
3. Bookshelf 1
4. Cupboard 1
5. Cart 1
6. washbasin 1
7. Non-medical trash 1
8. Tissue box 1
9. AC tissue box 1
10. Light 1
L. Nurse Station
1. Computer 3
2. air conditioning 3
3. TV 1
4. Wall clock 1
5. washbasin 1
6. Non-medical trash 1
7. Tissue box 1
8. Computer desk 3
9. Long table 1
10. Plastic chair 8
11. Wooden chairs 4
12. UPI Tools 2
13. sucksition tool 1
14. U cup 1
15. Photo reading light 1
16. Hand Sanitizer 1
17. Light 6
18. Phone 2
19. Printer 1
20. Bathroom 1
21. Closet sitting 1
22. Echo 1
23. fridge 1
24. Dispenser 1
M. Medicine Room
1. Medicine cabinet 1
2. child amubag 0
3. Adult amubag 2
4. Blood transfusion box 1
5. ecg tool 1
6. washbasin 1
7. Non-medical trash 1
8. Medical waste bin 1
9. Infectious trash 1
10. Needle trash can 1
11. Plastic chair 1
12. Alkel cupboard 1
13. tension cuff 4
14. Monitor 2
15. Nebulizer 1
16. Patslide 1
17. Adult SPO2 2
18. Stethoscope 3
19. Syring pump 1
20. Digital sphygmomanometer 1
21. Digital thermometer 2
22. infrared thermometer 1
23. Weigh 1
24. Tonge spatel 1
25. Tourniquet 4
26. Action trolley 1
27. Medicine trolley 1
28. Light 1
 29. Medicine fridge 1
30. Wound care kit 10
31. Electric air mattress 1
32. Patient bath trolley 1
33. Action trolley 1
34. WWZ 1
35. depart 1
36. Plastic measuring cup 1
37. Infusion pump 0
38. pediatric stethoscope 0
39. Neonatal SPO2 0
40. urinal rack 0
41. Flashlight 1

9. Documentation
The nursing documentation used in room C1 is the RS SIM (RSPAL
documentation system), which is computer-based which contains:
- On the main menu, medical personnel (doctors, nurses, nutritionists, pharmacists) will
log in to their accounts (use e-mail and password). After logging in, the main home
screen will appear which contains the main menu, patient data for each room, patient
data in the hospital which can be clicked according to what they want.
- In the first column, after entering the patient data in the room, a column for patient
data will appear, if you click on this patient data it contains: patient identity, including
name, identity card number, gender, age, place of birth , address, occupation, religion,
education level, and language. The second page contains the results of the assessment
from the patient and the nurse who carried out the assessment, as well as an
explanation of the patient's main complaints and history when they came to the
hospital and nursing diagnoses. On the 3rd page, there is a CPPT (patient
documentation representing collaboration between nurses, doctors, nutritionists, etc.).
The CPPT of nursing includes the latest data from patients, their assessment, nursing
diagnoses, vital signs, and interventions that have been performed on the patient.
- In the second column, it contains a summary of the patient's discharge which contains
the patient's discharge letter when leaving the hospital
- In the third column, it contains supporting examinations submitted by the radiology
team, containing the results of laboratory examinations, radiology and so on while the
patient is in the hospital.
- The fourth column contains nursing actions that contain nursing care plans. Nursing
notes and handover process
- In the fifth column, contains the surgery performed by the patient, if any. Usually the
operating doctor will fill in the patient's operating data in the form of an operating
schedule, surgery, type of surgery, name of the doctor who performed the operation,
type of surgical findings, antibiotics given, time of completion of surgery and some
operating documentation.
- In the sixth column, contains the patient's diet, in this column will be explained about
the dietary rules and the type of patient's diet and the patient's eating schedule
- In the seventh column, it contains the administration of drugs, in this column it is
explained about all the therapies given to patients while in the hospital including the
name of the drug, the dose of the drug and the name of the doctor who recommended
the drugs.
- In the eighth column, it contains the patient's bill while in the hospital which includes
the amount of expenditure for hospital care and the source of the funds (BPJS, self-
funding, and etc)
No. Data Problem Recommendation
Based on the results of the Discuss with nurse
questionnaire on the satisfaction managers to propose
of nurses while working in room equal incentives and
C1 that we have recapitulated, develop performance
most of the nurses chose appraisal instruments as
moderate satisfaction during a benchmark for
Nurse Satisfaction
work, nurses did not feel very achieving nurse
satisfied (100%) due to several performance that can be
1.
things such as additional assessed with incentives
incentives for work performance in the form of money.
that had not been implemented,
work space facilities had not
been implemented. maximum
and the amount of salary does
not match the nurse's
background.
No documentation through Make a note of every
2. Supervision
books supervision action.
Nurses do not explain patient
acceptance during MRS in a
Create a new patient
3. Patient admission coherent manner (3P) to newly
admission pocket book
admitted patients. In the
introduction to karu, katim, PP.
Creating/providing
Nurses do not provide
Discharge educational media
4. educational media that patients
Planning (leaflets/ booklets/ etc.)
can take home
about the 5 most cases

It is better if the task is

Nurses have used the team carried out according to
Nursing Care
5. method but what is implemented the job that has been
Method
is still functional determined and in
accordance with the
(MAKP) that has been
created and applies