NURSING

DOCUMENTATION

Oleh :
1. Agnanto Nurrohman D (1821001)
2. Alfiary Yusuf (1821002)
3. Andik Khoironi (1821003)
4. Armanda W (1821004)
 DEFINITION OF NURSING DOCUMENTATION

Nursing documentation is a document or record that

contains data about the patients condition which is seen
not only from the type of quality and quantity of services
the nurse has provide to meet the patients need. (Ali, 2010)

Understanding nursing documentation is a proof of

professional nursing services that contain all aspects of both
medication and treatment that are written regularly so that it
can describe the overall health condition of the patient.
(Setyowaty: 2005)
 THE MAIN PURPOSE OF NURSING
DOCUMENTATION

Confirm data on all members of the healh

team
Provide evidence for the purpose of evaluation
nursing care
As responsibility and accountability
As a method of developing nursing scince
 DOCUMENTATION OF NURSING PURPOSES

Identify client health status in order to

document client needs, plan, implement
nursing care and evaluate interventions.
Documentation for research, finance, law and
ethics.
 BENEFIT OF NURSING DOCUMENTATION

 As a legal document that nurses can use as a form of

accountability when a nurse is exposed to legal issues
related to his profession.
 To improve the quality of nursing care.
 As a rule of counting the cost of a patient’s care.
 As a study material for prospective nurses.
 For medical research.
 As a means of measuring success rates and accreditation
of nursing services.
 PRINCIPLES OF NURSING DOCUMENTATION

 There is a standard format that can be a reference.

 Made by the nurse concerned.
 Were made immediately after the nurse performed the
nursing act.
 In the documentation is chronological action of nursing.
 Abbreviations are allowed, but acronyms are commonly
used.
 Made fully with the times, dates, initials and signatures of
the maker.
 It must be made correctly, accurately, clearly, complete,
readeble and if in manual to be written in ink.
 If a wrong writing is not allowed to remove it with an ink
eraser, tipe-ex or something .
 T YPE OF NURSING DOCUMENTATION

1.SOR (Source Orientation Record)

2.POR (Problem Orientation Record)
3.Progress note
4.CBE (Charting By Exception)
5.PIE (Problems Intervention and Evaluation)
6.Focus
 ATTENTION TO DOCUMENTATION

1. DONT DELETE USING TIP-EX!

2. DONT WRITE CRITICAL COMMENTS!
3. CORRECT ALL ERRORS AS SOON AS POSSOBLE
4. RECORD ONLY FACTS ACCURATELY AND RELIABLY
5. DONT LEAVE AT THE END OF THE NURSES BLANK
NOTE !
6. ALL RECORDS MUST BE READABLE
7. START RECORDING WITH TIME AND END WITH A
SIGNATURE
 ASPECTS OF DOCUMENTATION

Accurate data
Breafity
Legality
 NURSE’S RESPONSIBILIT Y

Maintain accuracy
Record all nursing actions performed
Record all components of the nursing process
according to the time of implementation .
THANK YOU