BAHASA INGGRIS

OLEH

1. Ingrit Sarinigsi Ito

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2. Ivony Maryeri Bere Laka
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3. Kismi Aprilyani Napa
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4. Margaretha Naisaban
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5. Maria I. R. Amnanu
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TINGKAT 2 REGULER A
 NURSING DOCUMENTATION

A. Warmer
- The nurse againtalks to the patient, or ask the patient
- Patient
- Nurse. Wants to check on the patient’s condition
- Check up result
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
1)
- Assesment
- Planning
- Evalution
2) Dengan Terang
 Exercise 2
- Nurses create and edit patient records many times during any
work day. The Importance of documentation,we learn in nursing
school that a patient record is a legal document. We also learn that “if
it isn’t charted, It isn’t done.”
- Documentation in nursing is also an integral part of providing quality
and safe care to our patient
D. Writing
- NURSING DOCUMENTATION One of the duties of a nurse is to do nursing
documentation. Nursing documentation is a record containing patient
complaints and actions that must be taken by the nurse so that the patient
returns to health. Nursing documentation consists of assessment, nursing
diagnosis, planning, implementation and evaluation. The assessment is carried
out when the patient first enters the hospital, for example assessing the
patient's complaints so that they come to the hospital. follow-up studies to
complement the initial assessment such as conducting laboratory
examinations. then reassessment to determine the patient's progress, for
example, does the patient still feel dizzy? or can the patient perform personal
hygiene independently? Nursing diagnosis is the determination of clinical
nurse decisions for complaints and pain that the patient feels during the
assessment. For example, when the patient coughs with phlegm and has
difficulty breathing, a diagnosis can be made of "ineffective airway clearance
associated with retained secret". Planning is an action that will be taken by the
nurse so that the patient returns to health. For example, a patient who
experiences shortness of breath due to a cough with phlegm, the nurse should
plan for giving education on deep breathing and coughing effectively.
Implementation is the provision of actions that have been planned, such as
training the patient to cough effectively.Evaluation is to assess the patient's
progress based on the implementation done. such as after coughing effectively
2 times a day the patient shows a regular breathing pattern.therefore, a nurse
must carry out nursing documentation tasks according to the flow so that the
patient achieves health. a nurse must always be responsible for every action
taken.