Gambaran penerapan pendokumentasian early warning system score pada pasien kanker di satu rumah sakit swasta Indonesia bagian barat = description of early warning system score application on patients in west Indonesia private hospital

Saputro, Aris Hadi and Zendrato, Bryan Ifolala (2018) Gambaran penerapan pendokumentasian early warning system score pada pasien kanker di satu rumah sakit swasta Indonesia bagian barat = description of early warning system score application on patients in west Indonesia private hospital. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Early Warning System Score (EWS Score) merupakan suatu sistem penilaian terhadap perubahan keadaan pasien melalui pengamatan yang sistematis dengan enam parameter fisiologis yaitu tingkat pernapasan, saturasi oksigen, denyut jantung, tekanan darah sistolik, suhu dan status neurologis. Tujuan penelitian ini, untuk mengidentifikasi gambaran mengenai penerapan pendokumentasian EWS Score pada pasien Kanker melalui kelengkapan pendokumentasian parameter, kesesuaian hasil akhir EWS Score, dan analisis lembar observasi serta catatan integrasi. Desain penelitian ini adalah deskriptif kuantitatif-cross sectional study dengan studi dokumentasi. Populasi penelitian ini meliputi berkas rekam medis pasien dewasa usia di atas 16 tahun dan bukan ibu hamil dengan diagnosa medis kanker pada bulan Juni-Juli 2018, teknik convenience sampling dengan jumlah 60 sampel dokumen. Instrumen yang digunakan adalah audit checklist berdasarkan standar operasional prosedur (SOP) implementasi EWS Score melalui analisis lembar observasi dan catatan integrasi. Hasil penelitian mendapatkan dokumen dengan pendokumentasian parameter EWS Score secara lengkap adalah 0% (0 berkas), terdapat 71,7% (43 berkas) sesuai dalam penghitungan manual EWS Score. Pendokumentasian parameter EWS Score termasuk dalam kategori kurang diterapkan karena persentase parameter EWS Score yang didokumentasikan secara keseluruhan adalah 73,57% atau ≤ 80%. Rekomendasi untuk penelitian selanjutnya diharapkan dapat melihat faktor -faktor yang memengaruhi kepatuhan perawat dalam mendokumentasikan EWS Score = Early Warning System Score (EWS Score) is a system of assessment of the patient's condition changes through systematic observation with six physiological parameters namely respiratory rate, oxygen saturation, heart rate, systolic blood pressure, temperature and neurological status. The purpose of this study was to identify a description of the application of EWS Score documentation on Cancer patients through completeness of documentation of parameters, conformity of the final result of EWS Score, and analysis of observation sheet of vital signs and integrated note. The design of this research was descriptive quantitative-cross sectional with documentary studies. The population of this study included medical records of adult patients over 16 years old and not pregnant women with cancer medical diagnoses in June-July 2018, convenience sampling technique with 60 documents samples. The instrument used was observation sheet based on standard operating procedure (SOP) of implementation of EWS Score through analysis of observation sheets and integration notes. The results obtained by document documentation of EWS Score parameters are 0% (0 files), there were 71.7% (43 files) corresponding to EWS Score manual counting. Documentation of EWS Score parameters included in the less applied category because the percentage of the documented EWS Score parameters was 73.57% or ≤ 80% overall. Recommendations for further research are expected to look at factors affecting nurse compliance in documenting the EWS Score.

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