Gambaran pendokumentasian early warning score di lantai tujuh siloam hospitals makassar = description of early warning score documentation on seventh floor siloam hospitals makassar period juneaugust 2017

Songko, Indriani Permatasari (2018) Gambaran pendokumentasian early warning score di lantai tujuh siloam hospitals makassar = description of early warning score documentation on seventh floor siloam hospitals makassar period juneaugust 2017. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Background: Early Warning Score is an acute disease assessment conducted by a multidisciplinary team. According to Rogers et al (2008) one of the traditional roles of nurses is "surveillance." In addition, nurses also have an important role in documenting nursing care. Nursing documentation is evidence of nurse reporting or recording in caring for the patient. Purpose: This research is to describe the documentation of Early Warning Score in one unit at Siloam Hospitals Makassar. Method:Quantitative-descriptive research with study documentation approach. Population: All patient medical records on the seventh floor of Siloam Hospitals Makassar period from June to August 2017 are 943 files. Sample: Using simple random sampling technique with total sample is 281 files. Instruments: Using daily observation checklist sheets that have been adapted to Standard Operating Siloam Hospitals Makassar. Results: Most (79%) daily observation charts documented the value of Early Warning Score. Most (56%) integrated records do not document the value of Early Warning Score. Most (85%) early nursing assessments entered documenting the value of Early Warning Score. And most (55%) records did not document the value of the Early Warning Score. Suggestion: Head Nurse can supervise the Early Warning Score documentation every week. Furthermore, each Head Nurse can do briefings or short notice in advance about the Early Warning Score to the nurse before performing the service / Latar belakang: Early Warning Score adalah penilaian penyakit akut yang dilakukan oleh tim multidisplin. Menurut Rogers et al (2008) salah satu peran tradisional perawat adalah “surveilance” Selain itu, perawat juga mempunyai peran penting dalam pendokumentasian asuhan keperawatan. Dokumentasi keperawatan adalah bukti pelaporan atau pencatatan perawat dalam merawat pasien.Tujuan : Penelitian ini adalah untuk mendeskripsikan pendokumentasian Early Warning Score dalam satu unit di Siloam Hospitals Makassar.Metode :Penelitian kuantitatifdeskriptif dengan pendekatan studi dokumentasi. Populasi : Seluruh Rekam Medik pasien di lantai tujuh Siloam Hospitals Makassar periode Juni-Agustus 2017 adalah 943 berkas. Sampel : Menggunakan teknik simple random sampling dengan jumlah sampel adalah 281 berkas. Instrumen : Menggunakan lembar observasi check list yang telah disesuaikan dengan Standar Operasional Siloam Hospitals Makassar. Hasil penelitian : Sebagian besar (79%) lembar observasi harian mendokumentasikan nilai Early Warning Score. Sebagian besar (56%) integrated noted tidak mendokumentasikan nilai Early Warning Score. Sebagian besar (85%) pengkajian keperawatan awal masuk mendokumentasikan nilai Early Warning Score. Dan sebagian besar (55%) catatan serah terima pasien tidak mendokumetasikan nilai Early Warning Score. Saran : Head Nurse dapat melakukan supervisi dokumentasi Early Warning Score setiap minggunya. Selain itu, Head Nurse dapat melakukan briefing atau pemberitahuan ringkas terlebih dahulu mengenai Early Warning Score kepada perawat sebelum melakukan dinas.

Item Type: Thesis (Bachelor)
Creators:
CreatorsNIMEmail
Songko, Indriani PermatasariUNSPECIFIEDUNSPECIFIED
Contributors:
ContributionContributorsNIDN/NIDKEmail
Thesis advisorSumartiningsih, Maria SusilaUNSPECIFIEDUNSPECIFIED
Thesis advisorGuinda, CatharinaUNSPECIFIEDUNSPECIFIED
Uncontrolled Keywords: Early Warning Score;Kajian Dokumentasi; Rekam Medik; Early Warning Score; Documentation Review; Medical Record
Subjects: R Medicine > RT Nursing
Divisions: University Subject > Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing
Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing
Depositing User: Users 13 not found.
Date Deposited: 08 Jul 2019 08:25
Last Modified: 20 Jul 2020 04:48
URI: http://repository.uph.edu/id/eprint/3894

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