Gambaran Kelengkapan Pendokumentasian Catatan Perkembangan Pasien Terintegrasi (CPPT) oleh Perawat
DOI:
https://doi.org/10.32584/jpi.v8i2.3013Abstrak
Introduction: Medical records were files or documents that contain notes or status of patient development while in the hospital. The completeness of medical records, especially integrated patient development records (CPPT), is an important aspect of health services because it affects the quality and standard of hospital services. The purpose of this scientific paper was to identify the completeness of documentation of integrated patient development records by nurses in the anturium room of Dr. Soebandi Hospital, Jember.
Materials and methods: This type of research was a quantitative descriptive case study with the number of research samples used, namely 22 medical records obtained during data collection. The research instrument used was an observation checklist sheet of the completeness of CPPT documentation.
Results: The results showed that the patient identity component was 90.9% complete, important notes (SOAP) obtained 72.2% complete data, authentication data showed the highest percentage of 100% complete and the correct documentation data showed 63.3% complete data.
Conclusion: High-quality nursing documentation was essential because it reflects the quality and continuity of nursing care. Nurses are responsible for ensuring that documentation of care is carried out in a structured and comprehensive manner to facilitate communication between health workers and improve the quality of patient care.
Keywords: Completeness, Integrated Record, Inpatient Room
Unduhan
Diterbitkan
Terbitan
Bagian
Lisensi
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.
