Patient Centered Care (PCC) dalam Dokumentasi Keperawatan
DOI:
https://doi.org/10.32584/jkmk.v6i2.1834Keywords:
Patient cantered care, nursing record, nursing documentationAbstract
Pelayanan keperawatan harus berfokus pada pasien/patient centered care (PCC) dengan mengedepankan respon terhadap kebutuhan, nilai, keyakinan serta pilihan pasien. Dokumentasi keperawatan merupakan media komunikasi non verbal yang berperan penting dalam keberhasilan PCC, oleh sebab itu diperlukan tinjauan terkait PCC dalam dokumentasi keperawatan. Studi ini bertujuan untuk mengidentifikasi dan mensintesis hasil penelitian terkait dokumentasi keperawatan berdasarkan PCC. Digunakan metode pendekatan literature review dengan pencarian artikel pada enam basis data elektronik: PubMed, EBSCO, Cochrane Library, ProQuest, Scopus dan DOAJ. Teridentifikasi 262 artikel, yang kemudian dilakukan skrining berdasarkan kriteria inklusi berupa original artikel, sampel perawat, pasien maupun dokumentasi keperawatan PCC, diterbitkan dalam kurun waktu sepuluh tahun terakhir atau rentang tahun 2012 sampai tahun 2022, serta berbahasa Inggris. Hasil menunjukkan, lima studi memenuhi kriteria inklusi, termasuk empat studi kualitatif dan satu studi cross-sectional. Empat studi melaporkan variasi dalam kelengkapan pendokumentasian PCC, tiga studi menyoroti faktor-faktor, hambatan maupun tantangan dalam pendokumentasian PCC, serta dua studi menyimpulkan strategi dan rekomendasi terkait upaya peningkatan dokumentasi keperawatan PCC. Kajian ini menemukan wawasan baru yang komprehensif terkait rendahnya pelaksanaan dokumentasi PCC, tantangan, hambatan dan faktor penyebab, serta upaya peningkatan dokumentasi keperawatan PCC. Sehingga ini dapat berguna untuk rencana pengembangan strategi pendokumentasian berdasarkan PCC.References
Akhu-Zaheya, L., Al-Maaitah, R., & Bany Hani, S. (2018). Quality of nursing documentation: Paper-based health records versus electronic-based health records. Journal of Clinical Nursing, 27(3–4). https://doi.org/10.1111/jocn.14097
Alfajri, N., Sugiarsih, & Nurmastuti, H. (2017). Implementasi Case Management System di Ruamah Sakit. Gajah Mada University Press.
Arakelian, E., Swenne, C. L., Lindberg, S., Rudolfsson, G., & von Vogelsang, A. C. (2017). The meaning of person-centred care in the perioperative nursing context from the patient’s perspective – an integrative review. In Journal of Clinical Nursing (Vol. 26, Issues 17–18). https://doi.org/10.1111/jocn.13639
Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing care activities based on documentation. BMC Nursing, 18. https://doi.org/10.1186/s12912-019-0352-0
Broderick, M. C., & Coffey, A. (2013). Person-centred care in nursing documentation. International Journal of Older People Nursing, 8(4). https://doi.org/10.1111/opn.12012
Burridge, L., Foster, M., Jones, R., Geraghty, T., & Atresh, S. (2018). Person-centred care in a digital hospital: Observations and perspectives from a specialist rehabilitation setting. Australian Health Review, 42(5). https://doi.org/10.1071/AH17156
Dahm, M. R., Georgiou, A., Bryant, L., & Hemsley, B. (2019). Information infrastructure and quality person-centred support in supported accommodation: An integrative review. In Patient Education and Counseling (Vol. 102, Issue 8). https://doi.org/10.1016/j.pec.2019.03.008
De Groot, K., Triemstra, M., Paans, W., & Francke, A. L. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. In Journal of Advanced Nursing (Vol. 75, Issue 7). https://doi.org/10.1111/jan.13919
De Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R., & Matarese, M. (2010). “If it is not recorded, it has not been done!”? Consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19(11–12). https://doi.org/10.1111/j.1365-2702.2009.03012.x
Fauziyah, N. (2021). Pelibatan pasien dalam manajemen asuhan keperawatan (patient engagement in nursing care management). NEM.
Jarrar, M., Minai, M. S., Al-Bsheish, M., Meri, A., & Jaber, M. (2019). Hospital nurse shift length, patient-centered care, and the perceived quality and patient safety. International Journal of Health Planning and Management, 34(1). https://doi.org/10.1002/hpm.2656
Kolanowski, A., Van Haitsma, K., Penrod, J., Hill, N., & Yevchak, A. (2015). Wish we would have known that!" Communication breakdown impedes person-centered care. Gerontologist, 55. https://doi.org/10.1093/geront/gnv014
Kuipers, S. J., Cramm, J. M., & Nieboer, A. P. (2019). The importance of patient-centered care and co-creation of care for satisfaction with care and physical and social well-being of patients with multi-morbidity in the primary care setting. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-018-3818-y
Laitinen, H., Kaunonen, M., & Åstedt-Kurki, P. (2010). Patient-focused nursing documentation expressed by nurses. Journal of Clinical Nursing, 19(3–4). https://doi.org/10.1111/j.1365-2702.2009.02983.x
Lateef, M. A., & Mhlongo, E. M. (2022). A qualitative study on patient-centered care and perceptions of nurses regarding primary healthcare facilities in Nigeria. Cost Effectiveness and Resource Allocation : C/E, 20(1), 40. https://doi.org/10.1186/s12962-022-00375-y
Laukvik, L. B., Lyngstad, M., Rotegård, A. K., Slettebø, Å., & Fossum, M. (2022). Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review. BMC Nursing, 21(1), 84. https://doi.org/10.1186/s12912-022-00863-9
Lavander, P., Meriläinen, M., & Turkki, L. (2016). Working time use and division of labour among nurses and health-care workers in hospitals – a systematic review. Journal of Nursing Management, 24(8). https://doi.org/10.1111/jonm.12423
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3). https://doi.org/10.1111/jonm.12727
Myklebust, K. K., Bjørkly, S., & Råheim, M. (2018). Nursing documentation in inpatient psychiatry: The relevance of nurse–patient interactions in progress notes—A focus group study with mental health staff. Journal of Clinical Nursing, 27(3–4). https://doi.org/10.1111/jocn.14108
Nakate, G. M., Dahl, D., Petrucka, P., B. Drake, K., & Dunlap, R. (2015). The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital. Open Journal of Nursing, 05(12). https://doi.org/10.4236/ojn.2015.512113
O’Brien, A., Weaver, C., Settergren, T., Hook, M. L., & Ivory, C. H. (2015). EHR Documentation: The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes. Nursing Administration Quarterly, 39(4). https://doi.org/10.1097/NAQ.0000000000000132
Öhlén, J., Reimer-Kirkham, S., Astle, B., Håkanson, C., Lee, J., Eriksson, M., & Sawatzky, R. (2017). Person-centred care dialectics—Inquired in the context of palliative care. Nursing Philosophy, 18(4). https://doi.org/10.1111/nup.12177
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. In The BMJ (Vol. 372). https://doi.org/10.1136/bmj.n71
Paterson, C., Roberts, C., & Bail, K. (2022). ‘Paper care not patient care’: Nurse and patient experiences of comprehensive risk assessment and care plan documentation in hospital. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16291
Pilnick, A. (2022). What Is Patient Centred Care? In Reconsidering Patient Centred Care. https://doi.org/10.1108/978-1-80071-743-520221002
Rahmi, U. (2019). Dokumentasi Keperawatan (B. S. Fatmawati, Ed.). Bumi Medika.
Saranto, K., & Kinnunen, U. M. (2009). Evaluating nursing documentation - Research designs and methods: Systematic review. Journal of Advanced Nursing, 65(3). https://doi.org/10.1111/j.1365-2648.2008.04914.x
Shiells, K., Holmerova, I., Steffl, M., & Stepankova, O. (2019). Electronic patient records as a tool to facilitate care provision in nursing homes: an integrative review. Informatics for Health & Social Care, 44(3), 262–277. https://doi.org/10.1080/17538157.2018.1496091
Søndergaard, S. F., Lorentzen, V., Sørensen, E. E., & Frederiksen, K. (2017). The documentation practice of perioperative nurses: a literature review. In Journal of Clinical Nursing (Vol. 26, Issues 13–14). https://doi.org/10.1111/jocn.13445
Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2020). Unsafe nursing documentation: A qualitative content analysis. Nursing Ethics, 27(5). https://doi.org/10.1177/0969733019871682
Tandi, D. (2020). Peningkatan Kelengkapan Dokumentasi Asuhan Keperawatan dengan Pendekatan Supervisi di RSUD dr. M. Haulussy Ambon. Universitas Hasanuddin Makassar.
Tubaishat, A. (2019). The effect of electronic health records on patient safety: A qualitative exploratory study. Informatics for Health and Social Care, 44(1). https://doi.org/10.1080/17538157.2017.1398753
Valdez-Delgado, K., Barba, M., Kulyen, A., Colston, P., Boyer, S., & Mann-Salinas, E. (2018). 1002: Evolution Of An Evidence-Based Competency Assessment Program For Specialty Nursing. Critical Care Medicine, 46(1). https://doi.org/10.1097/01.ccm.0000529009.61144.72
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2023 Vinny Vionita Bawuno, Kadek Ayu Erika, Yuliana Syam
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with this journal agree to the following terms:
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
This work is licensed under a Creative Commons Attribution 4.0 International License.
