This document discusses nursing documentation. It begins by defining nursing documentation as a systematic method to identify clients, plan problem-solving strategies, and evaluate nursing actions. It then lists some benefits of documentation such as preventing neglect, providing organized nursing care, and encouraging patient participation. The document also discusses some purposes of documentation like improving accuracy and reducing errors. It provides some standards for documentation and lists some common models of nursing documentation that include source-oriented records and problem-oriented records. Finally, it briefly discusses some legal aspects of documentation such as common data components required by law and how documentation can be used as evidence in court cases.

1. BY :
GRUP 10
1. DEFRY APRILIANDI
(email : defrieodot@yahoo.co.id)
2. TITIN ANDRIANA
(titinandrianaa@gmail.com)
NURSING ACADEMY OF
EAST KOTAWARINGIN
www.akperkotim.ac.id

2. THERE IS KNOWING
HOW DOCUMENTING
IN NURSING

3. DOCUMENTATION
 Nursing documentation is a
systematic method to identify the
client, plan, implement problem-
solving strategies and evaluate the
effectiveness of nursing actions
that have given (Kozier and ERB)
 Solving methods still in nursing
care that has been given includes
four steps: assessment, planning,
implementation and evaluation
(Ellis and Nowlis)

4. BENEFITS OF NURSING
DOCUMENTATION
1. Preventing neglect and countermeasures
unnecessary.
2. Provide flexibility in providing nursing care
3. Encourage client participation.
4. Give satisfaction to the nurse.
5. There is an organized method in nursing care

5. DOCUMENTATION PURPOSES
 As a means of documentation to help the
implementation of care provided by the team to
increase their accuracy and reduce errors and help to
achieve the effectiveness and efficiency of time

6. STANDARD DOCUMENTATION
a. Standard I systematic data
collection on the health
status of client data acquired
last discussed written /
recorded.
b. Standard 2 nursing diagnoses
to be obtained from the
client's health status data.
c. Standard 3 plan nursing and
expected results obtained
from nursing diagnoses.
d. Standard 4 nursing media
plan including medical
approaches to measure the
progress of disease acquired
in nursing diagnoses.
a) Standard 5 The attitude
of nurses to patients is
necessary for the healing
process.
b) Standard 6 Attitudes
treatments help patients
to improve the health.
c) Standard 7 Progress and
setbacks client's health is
determined by the client
and the nurse.
d) Standard 8 Progress and
setbacks recorded and
documented as well as
revisions to the plan to
the next nursing.

7. MODEL DOCUMENTATION OF
NURSING
 TERDIRI DARI 7 KOMPONEN :
1. SOR (SOURCE ORIENTED RECORD)
2. POR (PROBLEM ORIENTED
RECORD)
3. POR (PROGRESS-ORIENTED
RECORD)
4. CBE (CHARTING BY EXEPTION)
5. PIE (PROBLEM-INTERVENTION-
EVALUTION)
6. POS (PROCESS ORIENTED SYSTEM)
7. SYSTEM DOCUMENTATION CORE

8. LEGAL ASPECTS OF DOCUMENTATION
1. Common components of data according to the law
2. Guidelines for recording data according to the law
3. Method of recording data
4. A situation which gives guidance tendency in court
5. Relations legality ethics in nursing documentation
Insurers answers nursing services through nursing
documentation.

9. THANK YOU