Paper

Documentation Model Nursing care

Supervisors : Asmawati, S.Kp, M.Kep

Arranged by :

 Abilah Almubaroqah P01720322051

 Irfan Fazrul Pratama P01720322076
 Mela Apriana Dewi P01720322080
 Pita Ayu Azari P01720322086
 Riri Agustina P01720322088
 Tari Diaslara Putri P01720322039

Course : Nursing Documentation

HEALTH POLYTECHNIC, BENGKULU MINISTRY OF HEALTH

BACHELOR OF APPLIED NURSING PROFESSION AND

PROFESSIONAL NERS CLASS OF RKI

2023/2024
 FOREWORD

Praise be to the presence of Allah SWT, God Almighty for all His blessings
so that this paper with the title "Nursing care documentation model" can be
compiled to completion. We also do not forget to thank our Supervisor Mam
Asmawati, S.Kp, M.Kep for her guidance and direction in the process of
preparing this paper.

The preparation of this paper aims to fulfill the value of assignments in the
Nursing Documentation course. In addition, the preparation of this paper also
aims to add knowledge and insight to the readers.

Due to limited knowledge and experience, we believe there are still many
shortcomings in this paper. Therefore, we really hope for constructive criticism
and suggestions from readers for the perfection of this paper.

Finally, I hope this paper can be useful for readers

Bengkulu, 31 July 2023

1
 LIST OF CONTENTS

FOREWORD.......................................................................................................................1
LIST OF CONTENTS.........................................................................................................2
CHAPTER I INTRODUCTION..........................................................................................2
1.1 Background................................................................................................................2
1.2. Formulation of the problem......................................................................................3
1.3. Objective...................................................................................................................3
CHAPTER II DISCUSSION...............................................................................................3
2.1. SOR documentation model (source oriented record)................................................3
2.2. POR (Problem-oriented-record) documentation model............................................5
2.3. CBE documentation model (charting by exception).................................................7
CHAPTER III CLOSING....................................................................................................8
3.1. Conclusion................................................................................................................8
3.2. Suggestion.................................................................................................................9
BIBLIOGRAPHY................................................................................................................9

2
 CHAPTER I

INTRODUCTION

1.1. Background

Nursing documentation has been deemed necessary since the time of

Florence Nightingale, nursing documentation is written information about the
status and development of a patient's health condition as well as all nursing
care activities carried out by a nurse. As written information, nursing
documentation is an effective medium of communication between nurses and
nurses. between nurses and other professions in a health service setting that
aims to see and analyze the development of the client's health condition.
Besides that, nursing documentation aims to plan patient care as an
indicator of the quality of health services, a source of data for research, as
evidence of accountability and accountability for the implementation of
nursing care, and as a means of education for students and students.
Nursing documentation is a written accountability of a number of
facts and events/problems that have been identified. This documentation is a
special patient record used by nurses in providing research nursing care and
most importantly as the nurse's responsibility and accountability for nursing
services provided to patients/clients.

1.2. Formulation of the problem

1) How is the documentation technique with the SOR model?

2) What is the documentation technique with the POR model?
3) How is the documentation technique with the CBE model?

1.3. Objective

1) To find out how to document the SOR model

2) To find out how to document the POR model
3) To find out how to document the CBE model

3
 CHAPTER II

DISCUSSION

2.1. SOR documentation model (source oriented record)

The SOR (source-oriented-record) documentation model is a

documentation model that is oriented towards information sources. This model
locates records on the basis of the discipline of the person or resource managing
the records. Documentation is made by each member of the health team making
their own notes from the observations. Then, all the documentation results are
collected into one. So that each member of the health team carries out their own
activities without depending on other members of the health team. For example, a
collection of documentation sourced from doctors, midwives, nurses,
physiotherapists, nutritionists, and others. Doctors use sheets to record
instructions, history sheets and disease progression. Nurses use nursing records, as
well as other disciplines have their own records.
This model can be applied to inpatients, in which there are notes on
doctor's messages written by doctors, and nursing history written by nurses.
However, in general this note is in the form of a doctor's message. The records in
this model are placed on the basis of the discipline of the person or source who
processes the documentation.
This SOR documentation model can be made with graphic forms, medication
administration formats, nurse record formats including the client's medical
history, treatment history and patient development, laboratory examinations and
diagnostic examinations, hospital admission forms and forms for operations
signed by the patient and family.

The SOR documentation model consists of 5 components, namely:

1. The acceptance sheet contains biodata
2. Doctor's Instruction Sheet
3. Medical history or disease sheet
4. Nurse's notes
5. Special notes and reports.

Example from 5 components :

Acceptance sheet containing biodata

Client identity
Name : Tn. A
Religion : Islam
Address : Jl. Muhammad RT 2/ RW 2 No. 73
Gender : Male
Education : SMA
Work : Labor

4
Status : Unmarried
Entry date : 28 July 2023
Medical diagnosis : Abdomen pain
Room : Rose K388

Identity of the Person in

Charge
Name : Ny. R
Age : 40 th
Address : Jl. Muhammad RT 2/ RW 2 No. 73
Gender : Female
Education : SD
Occupation : Labor
Client relationship : Biological mother

 Doctor's Instruction Sheet

Doctor's instruction Name : Mr. A Age : 19 years old

sheet RM No : 098980
Address : JL.
Muhammad RT 2/ No.
73, Bandung
Date/hour Doctor's Instructions TTD
Clear name

September 28/ 09.00 1. Give inj. Ketorolac Siti

2x30 mg
2. Give ranithidine 2x50
mg
3. Peroral antacid 3x1
tablets

 Medical or disease history sheet

MEDICAL HISTORY Name : Mr. A Age : 19 years old

SHEET RM No : 098980
Address : JL.
Muhammad RT 2/ No.
73, Bandung
Date/hour Medical History
September 28 / 08.00 The client said abdominal pain in the upper right, if
WIB sleeping on your back it hurts very much, like a
prickling, pain felt on a scale of 8 is severe pain and
the pain is continuous. Clients also reported nausea,
weakness, and insomnia. The client has never
previously experienced the same illness and none of
the client's family has ever suffered from this

5
 disease. The client also said that he had no appetite
to only spend 1/2 portion of his meal, and irregular
defecation (3 days have not defecated), BAK only
3-4 times a day, his activities were assisted by
family, blood pressure 110/70 mmhg, pulse 80 x /
minute, RR 20 X / minute, S-37 ° C

 Nurse's notes

Nurse's notes Name : Mr. A Age : 19 years old

RM No : 098980
Address : JL.
Muhammad RT 2/ No.
73, Bandung
Date/hour Nurse's notes TTD
Clear name

September 28 / 08.00 The client still complains Mariam

WIB of pain in the upper
abdomen with a scale of
still 8, the client looks
weak, nausea, difficulty
sleeping

 Special Report Notes

Special report notes Name : Mr. A Age : 19 years old

RM No : 098980
Address : JL. Muhammad RT
2/ No. 73, Bandung
Date/hour Special notes and reports
September 28 / 08.00 Eat rice porridge and recommend drinking plenty of
WIB water and eating little but often to keep the stomach
filled

The advantages of the SOR (source-oriented-record) documentation model are:

1. Present sequential and easily identifiable data,
2. Make it easier for nurses to do documentation,
3. The documenting process is simplified.

While the disadvantages are:

1. There is potential for fragmented data collection because it is not based on
time sequence.
2. Superficial recording without clear data.
3. Requires data analysis from several sources to determine the problem and
action for the client.

6
2.2. POR (Problem-oriented-record) documentation model

The POR (problem-oriented-record) documentation model is a problem-

oriented documentation model. Where this model is centered on client data that is
documented and arranged according to client problems. This approach was first
introduced by dr. Lawrence Weed from the United States. In its original format, this
problem-oriented approach was created to facilitate documentation with integrated
progress notes, with this system all health workers record their observations from a
list of problems. Components of the POR documentation model:
a. Basic data is a collection of information about the client which contains all
the information that has been reviewed from the client since he was first
admitted to the hospital. This basic data includes: the client's history of the
client's general condition, family history, the state of the disease experienced
by the patient, nursing actions that have been given, physical examination,
and supporting data (laboratory and diagnostic).
b. The list of problems is the result of interpretation of the basic data or the
results of analysis of data changes. This list reflects conditions or values that
are not normal from the data obtained by using the order of priority written
into the problem list and given at each change of shift. The criteria for the list
of problems made are: Data that has been identified from the basic data is
arranged according to the date of identification of the problem. The list of
problems is written for the first time by the nurse who meets the client for the
first time or the person who is responsible for writing it. This list is on the
front of the client's status. , Each problem is given a date, number, problem
statement, and the name of the nurse who discovered the problem.
c. The initial list of nursing care plans is a plan that can be developed
specifically for each problem. The initial list of nursing care plans consists of
three components, namely: Diagnostic Examination, Case Management or
also known as proposed therapy, and Health education (as a long-term goal).
d. Progress notes are notes about the progress of the client's condition based on
any problems found with the client. Revision or updating of plans and actions
following changes in the client's circumstances. This development record
contains the development or progress of each client's health problems.
Progress notes can be used in the form: SOAP, SOAPIER, and PIE.

Example of POR nursing documentation model format

Basic Data Problem List Intervention Plan Progress notes

DS: the client Impaired skin -Promoting S:
complains of integrity bd sports  The client
pain in the mechanical says he can't
surgical wound factor (physical to clients such as move
immobility) doing light
DO: on the exercise  The client
client's abdomen (stretching in the says if the

7
 there is a morning or doing activity is
postoperative a light warm-up assisted.
wound with a to stretch the
length of + 15cm muscles).  The client
ventricle (independent) complains
Td: 130/90 that his leg is
mmhg - Rest care in traction.
N: 80x/i
Q: 20x/i Perform rest O:
nursing actions  The client
to clients to looks
overcome grimaced
damage. skin
integrity based  The patient's
on mechanical BP is 130/80
factors. mm Hg
(Independent)
A:
-foot care
 Problem not
Perform foot care resolved
such as light
massage to help Q:
the patient
recover  Intervention
continued
- Bleeding Doing drug
reduction administration
Take action

Advantages of the POR (problem-oriented-record) documentation model:

a. The focus of nursing care records is more emphasis on patient problems
and the problem solving process.
b. Documentation of nursing care is carried out continuously.
c. Evaluation and problem solving are clearly documented.
d. The problem list is a check list for patient problems.

The disadvantages of the POR (problem-oriented-record) documentation model

are:
a. It can cause confusion if every item has to be included in the problem list.
b. Recording using the SOAPIER form, may cause unnecessary repetition.

2.3. CBE documentation model (charting by exception)

The CBE documentation model (charting by exception) is a

documentation system that only records results or findings that deviate from the

8
body's normal state. Deviations referred to in this case relate to unhealthy
conditions that interfere with the patient's health.
The CBE (Charting By Exception) Documentation Model Components include:
a. Documentation in the form of conclusions from important findings and
describes the assessment indicators.
b. In this case the findings include instructions from the Doctor or Nurse, as
well as records of the patient's education and discharge.
c. This documentation is based on standard nursing practice.

The advantages of the CBE (Charting By Exception) documentation model are:

a. Established minimum standards for nursing assessment and investigation.
b. Abnormal data is obvious.
c. Abnormal data is easy to flag.
d. Save time or documentation sheets.
e. Duplicate or duplicate documentation can be reduced.

Disadvantages of the CBE (Charting By Exception) documentation model are:

a. Documentation really depends on the check list that is made.
b. There may be undocumented incidents.
c. Routine documentation is often neglected.
d. Does not accommodate the documentation of other science divisions.

The guidelines for writing the CBE (Charting By Exception) documentation

model are:
a. Baseline data is documented for each patient and kept as a permanent
record.
b. The list of nursing diagnoses is written when the patient is first admitted to
the hospital and provides a checklist for all nursing diagnoses.
c. Patient discharge summaries were written for each diagnosis.
d. SOAPIER is used as a record of the patient's response to the intervention
that will be given to the patient.
e. Nursing diagnosis data and action plans can be developed.

9
Perbedaan SOR POR CBE
Man Setiap disiplin Hanya berisi data Berisi instruksi
orang atau dokumentasi dokter dan
sumber membuat masalah klien, perawat
catatannya rencana Tindakan
masing-masing dan catatan
perkembangan
dari perawat
Material Datanya terpisah- Model ini paling Tidak banyak
pisah dan bagus, karena kalimat atau
kedalaman fokus pada narasi. Hanya
datanya kurang penyelesaian berbentuk seperti
bagus karena masalah klien check list atau
berdasarkan grafik
kemampuan dari
masing-masing
disiplin.
Money
ekonomi

10
 method

CHAPTER III

CLOSING

3.1. Conclusion

As a medical professional, especially in the field of nursing, nursing

care must be considered. Nursing care is closely related to nursing
documentation. In nursing documentation consists of several kinds of models
which include:
1. SOR documentation model (source-oriented-record)
2. POR documentation model (problem-oriented-record)
3. CBE documentation model (charting by exception)
Nursing students must learn to understand nursing documentation
models and be able to apply them in nursing documentation. Complete
nursing care requires complete, objective and reliable data. The provision of
nursing care concerns service providers and service users so it needs to be
recorded completely and clearly for the common good. To facilitate the work
of nurses in providing nursing care and as a guarantee of quality so that
nursing documentation activities are recorded systematically within a certain
period of time in a clear, complete and objective manner

3.2. Suggestion

The author hopes that readers can provide criticism or suggestions for the
work of this paper, because this paper has advantages and disadvantages that
are educational or guiding.

11
 BIBLIOGRAPHY

Eriyani. 2020. Teaching Materials for Nursing Documentation. Medan: High

School of Health Sciences Binalita Sudama Medan.

Dinarti, A. (2009). Nursing Documentation. Jakarta: Trans Info Media

Hutaheen, Serii. (2010). Nursing Process Concepts and Documentation. Jakarta:

Trans Info Media Jakarta

Noorkasiani, N., Gustina, R., & Maryam, S. (2015). Factors Associated with
Completeness of Nursing Documentation. Indonesian Journal of Nursing, 18
(1), 1-8.

12