Metode Pendokumentasian Elektronik dalam Meningkatkan Kualitas Pelayanan Keperawatan

Authors

  • Sulastri Sulastri Jurusan Keperawatan, Poltekkes Tanjungkarang
  • Niken Yuniar Sari 2Program Studi Ners, Sekolah Tinggi Kesehatan Mitra Lampung

DOI:

https://doi.org/10.26630/jk.v9i3.987

Keywords:

Computerization, Documentation, Nursing, Technology information

Abstract

Nursing documentation is one of the most important functions for nurses in providing nursing care. The nursing process in the modern era is now a demand from various aspects for nurses. The current development is that nurses must carry out nursing processes based on nursing care standards. The use of electronic nursing documentation can always evolve in line with technological developments, this can increase client life expectancy and reduce errors in intervening with clients. This IT-based documentation system will help in meeting documentation standards, can improve the quality of documentation, facilitate decision making and provide information that is easy to access, can minimize the potential for loss or damage to development records, improve information exchange and coordination between nurses or other health teams, documentation can be easily audited, help improve the accuracy of client data, can access the progress of client health development and reduce maintenance costs so that it can improve the quality of care services.

References

American Hospital Association. 2001. Patient or paper work. The regulatory burden facing America’s Hospital. http:/tinyurl.com/cfnmvqc.

Blair, W., & Barbara Smith. 2012. Nursing Documentation: Framewor and Barriers. Contemporary Nurse, 41(2), 160–168.

Chand, S. 2014. Electronic nursing documentation. International Journal of Information Dissemination and Technology, 4(4), 328. http://search.proquest.com/openview/d6d55f2afd6a05546fe10097d559980a/1?pq-origsite=gscholar.

Hickey, A., Gleeson, M., & Kellett, J. 2012. READS: the rapid electronic assessment documentation system. British Journal of Nursing, 21(22), 1333-1339.

John, S. K., & Bhattacharya, C. 2016. Documentation guidelines based on expectation of documentation helps accurate documentation among nurses in psychiatric settings. Asian Journal of Nursing Education and Research, 6(2), 260.

Kamau, Nancy. 2015. Electronic Health Documentation and Its Impact on Nurses Routine Practices Literature Review. https://www.theseus.fi/bitstream/handle/10024/104801/Nancy%20Kamau%20PDF.pdf?sequence=1.

Kelley TF, Brandon DH, & Docherty SL. 2011. Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care. Journal of Nursing Scholarship, 43(2):154-62.

Lovlien, C. a, Johansen, M., Timm, S., Eversman, S., Gusa, D., & Twedell, D. 2007. Improving program documentation quality through the application of continuous improvement processes. Journal of Continuing Education in Nursing, 38, 271-276.

Moody, L. E., Slocumb, E., Berg, B., & Jackson, D. 2004. Electronic health records documentation in nursing: nurses' perceptions, attitudes, and preferences. CIN: Computers, Informatics, Nursing, 22(6), 337-344.

Nokes, Kathleen M., Aponte, Judith, Nickitas, Donna M., Mahon, Pamela Y., Rodgers, Betsy, Reyes, Nancy, . . . Dornbaum, Martin. 2012. Teaching Home Care Electronic Documentation Skills to Undergraduate Nursing Students. Nursing Education Perspectives, 33(2), 111-115.

Potter. 2005. Fundamentals Of Nursing: Concepts Process And Practice. California: Addison Wesley.

Smith, K., Smith, V., Krugman, M., & Oman, K. 2005. Evaluating the impact of computerized clinical documentation. Computers, Informatics, Nursing : CIN, 23(3), 132–138. http://doi.org/10.1097/00024665-200505000-00008.

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Published

31-12-2018