Gambaran kesesuaian pendokumentasian skoring early warning score (ews) pada pasien di unit orchid di siloam hospitals lippo cikarang = the scoring documentation match in the early warning score (ews) for patients in orchid unit of siloam hospitals lippo cikarang.

Pangastuti, Maya Dewi (2018) Gambaran kesesuaian pendokumentasian skoring early warning score (ews) pada pasien di unit orchid di siloam hospitals lippo cikarang = the scoring documentation match in the early warning score (ews) for patients in orchid unit of siloam hospitals lippo cikarang. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

EWS merupakan suatu sistem yang bertujuan untuk memprediksi pasien mana yang membutuhkan bantuan, penerapan manajemen pencegahan, sehingga dapat menentukan kondisi pasien jika mengalami perubahan fisiologis agar mendapatkan perawatan lebih lanjut. Pada rekapan audit dokumentasi bulan Januari – Mei 2017 di Siloam Hospitals Lippo Cikarang terdapat 36,84% tenaga medis yang tidak konsisten dalam penerapan EWS pada pasien. Tujuan penelitian ini adalah untuk mengidentifikasi gambaran kesesuaian pendokumentasian skoring EWS pada pasien di unit Orchid Siloam Hospitals Lippo Cikarang. Peneliti menggunakan metode kuantitatif deskriptif dengan menggunakan studi dokumentasi. Teknik pengambilan sampel dalam penelitian ini adalah accidental sampling dengan kriteria inklusi. Peneliti mengambil sampel sebanyak 50 dokumen pasien untuk dilakukan observasi dokumen. Populasi penelitian adalah dokumen pasien di unit Orchid Siloam Hospitals Lippo Cikarang periode November 2017. Data yang diambil menggunakan lembar observasi yang diadopsi berdasarkan Royal College Physicians (2012). Observasi dokumentasi yang peneliti lakukan yaitu dengan cara mengobservasi skoring EWS pada lembar catatan perkembangan terintegrasi dan catatan observasi pasien yang di catat oleh perawat. Hasil yang didapatkan sebagian besar yaitu 40 dokumen (80%) ditemukan tidak memiliki kesesuai penilaian skoring EWS antara lembar catatan terintegrasi dengan lembar catatan observasi. Peneliti menyarankan penelitian selanjutnya agar menggunakan alat ukur yang diuji validitas dan reliabilitas supaya dapat diterapkan untuk di dalam setting yang lebih umum / EWS is a system aiming to predict which patient needs help in the prevention management application, so that it would be able to determine the condition of the patient with physiological changes to receive further treatment. On the documentation of January-May 2017 audit recapitulation in Siloam Hospitals Lippo Cikarang there are 36.84% inconsistencies within the application of EWS on patients. The purpose of this research is to identify the matching of EWS scoring documentation on patients in Orchid unit of Siloam Hospitals Lippo Cikarang. Researcher uses descriptive quantitative method with the documentation studies as resources. The sampling technique in this research is accidental sampling with inclusion criteria. Researcher takes as many as 50 patients as samples to undergone document observation. The research population are the documented patients in Orchid unit of Siloam Hospitals Lippo Cikarang in the November 2017 period. Data were taken using an adopted observation sheet based on Royal College Physicians (2012). The documentation observation was done by observing the EWS scores on the integrated development notes and observation records of patients recorded by nurses. As a result, 40 documents (80%) were found to be incompatible with the EWS scoring between the integrated notes and the observation records. Researcher suggests that future researches uses tested valid and reliable tools in order to be applied in a more general setting.

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