Gambaran pendokumentasian implementasi early warning score di ruang rawat inap siloam hospitals lippo cikarang = documentation implementation of early warning score at ward siloam hospitals lippo cikarang.

Pardede, Desi Hotma (2018) Gambaran pendokumentasian implementasi early warning score di ruang rawat inap siloam hospitals lippo cikarang = documentation implementation of early warning score at ward siloam hospitals lippo cikarang. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Early Warning Score (EWS) is an early detection system that is effective in assessing worsening physiological conditions and determines clinical response by scoring and monitoring the combination of vital signs, awareness and oxygen use. Objective : Identify documentation implementation of EWS at non-critical care area through scoring, monitoring frequency and completeness of vital sign measurements. Research design : quantitative – documentation study. The Population : all the files of non-crtical care area by purposive sampling. Instrument : observation check list based on standard operating procedure (SOP) through analysis of integrated notes and manual calculations of vital signs of observation sheets. Result : implementation of EWS according to SOP only reaches 40% (12 files) and 43% (13 files) with no completeness of vital signs measurement and 17% (5 files) is wrong in scoring. The study of vital signs completeness was 46% (6 files) with no respiratory frequency and temperature, 46% (6 files) was not measured by respiration frequency and blood pressure was 8% (1 file) so that the frequency of breathing was the most frequent parameter to be measured. Recommendation : further research are expected to look at factors that affect the inaccuracy of EWS implementation / Early Warning Score (EWS) merupakan sistem deteksi dini yang efektif dalam menilai perburukan kondisi fisiologis dan menetukan respon klinis dengan melakukan scoring dan monitoring terhadap kombinasi dari tanda-tanda vital, kesadaran dan penggunaan oksigen. Tujuan : mengidentifikasi gambaran pendokumentasian implementasi EWS diruang rawat inap non-critical area melalui scoring, frekuensi monitoring dan kelengkapan pengukuran tanda-tanda vital. Desain penelitian : deskriptif kuantitatif dengan studi dokumentasi. Populasi : seluruh file pasien di ruang rawat inap dengan purposive sampling. Kriteria inklusi : file pasien dengan usai diatas 16 tahun dan bukan ibu hamil. Kriteria ekslusi : file pasien dibawah usia 16 tahun dan ibu hamil dan file pasien dengan persiapan pulang. File yang diteliti sebanyak 30 file. Instrumen : observasi check list berdasarkan standar oprasional prosedur (SOP) melalui analisa catatan terintegrasi keperawatan dan lembar observasi tanda vital. Hasil penelitian : Implementasi EWS mencapai 40% (12 file) dan 43% (13 file)dengan tidak memilki kelengkapan pengukuran TTV serta 17% ( 5 file) salah dalam melakukan skoring. Penelitian terhadap kelengkapan TTV terdapat 46% (6 file) tidak ada frekuensi pernafasaan dan suhu, terdapat 46% (6 file) yang tidak diukur frekuensi pernafasaannya saja serta tekanan darah yaitu 8% (1 file) sehingga frekuensi pernafasaan adalah parameter yang paling sering tidak diukur. Rekomendasi : penelitian selanjutnya diharapkan dapat melihat faktor-faktor yang memengaruhi ketidaktepatan implementasi EWS.

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