Nursing Documentation Standards
Kamis, 12 Januari 2023
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1. The Importance of Documentation Standards
Standard is defined as a measure or model of something that is almost the same. The model includes quality, characteristic properties, and expected performance in an action, service and all components involved. The value of a standard is determined by the use of consistency and evaluation. A nursing standard is a statement describing the qualities, characteristics, properties, or performance expected of some aspect of nursing practice.
Nurses need a documentation standard as a guide and direction towards proper storage and recording techniques. Therefore, the standards must be understood by colleagues and other health professionals, including the accreditation team. Anyone who needs accurate nursing records and useful information has the right to have such documentation in accordance with applicable standards. If standards are observable, nurses, workers, and patients will be respected and protected from misconduct.
Characteristics common to all standards overall | General characteristics of nursing standards |
| 1.Based on the definition of nursing and the nursing process that has been determined. |
| 2.Applicable to all practical care in the health care system. |
| 3. Instructions for nursing actions |
| 4.Can be maintained and optimal health promotion. |
| 5. The language is meaningful and understood by nurses who implement these standards. It can be obtained by anyone who needs it. |
2. Professional Individual Responsibility Standards
Implementation of standards can be achieved at the individual level. For the individual nurse this means demonstrating responsibility for the documentation of nursing practice within the context of the nursing process. By assuming responsibility and good quality work in nursing practice, including documentation of independent and interdependent actions.
Participation in implementing codes (such as the ANA code) on the part of nurses implies responsibility. This code provides guidance for individual practitioners so that their responsibilities to individual patients and society can be fulfilled.
3. Individual Professional Accountability Standards
The individual professional accountability standard describes the nurse's responsibilities in documenting nursing practice based on the nursing process. The responsibility to do the best in nursing practice includes independent and independent documentation activities.
1. Ten Standards of Nursing Measures (from ANA, 1973)
Nurses have the responsibility:
a. Providing services by respecting clients as living beings.
b. Protect patient rights (privacy; confidential).
c. Maintain competence in nursing actions and know the patient and accept personal responsibility for his actions.
d. Protect patients if their actions and safety are caused by other people who are incompetent, unethical and illegal.
e. Using individual ability as a criterion for accepting responsibility and delegating tasks in nursing actions to other health workers.
f. Participation in research activities if the respondent's rights are protected.
g. Participation in the activities of the nursing profession to improve the standard of nursing service practice and education.
h. Improving and maintaining the nursing quality of other nurses by participating in professional activities.
i. Promote health by working with communities and other health workers.
j. Refuse to consent to the promotion or sale of commercial products, services or other entertainment.
2. Scope of Independent Activities
The responsibilities of an independent nurse in documentation activities include:
a. Maintain accuracy of nursing service records, together with data and results of monitoring, observing, and evaluating the client's health status, so that the documentation remains consistent with the doctor's program and nursing actions.
b. Record all nursing actions used to reduce or prevent patient risk and maintain safety.
c. Record all patient care actions. The nurse responds to the clinical situation and determines the next action plan. These responses include assessments regarding treatment administration, nursing actions to provide comfortable rest, plans for client education, determination of self-care levels, and assessments of the results of consultations with other health teams.
d. Record all components of the nursing process according to the time of implementation. These components include the review, the nursing diagnosis, the goal modification action plan, and the client's teaching notes.
3. Interdependent Scope of Action
Interdependent activities are nursing activities, which are carried out in teams with other health professionals. Knowledge, skills and focus of nursing practice are interdependent activities. Documentation of the overall segment of the medical plan initiated by other departments (such as pharmacy or blood bank) but carried out by the nurse.
During interdependent activities, nurses make nursing plans with other members of the health team (doctors, pharmacists, nutritionists, physiotherapists). Nursing records need to reflect a description of where a process was carried out. At this stage it is important to document the reasons for "writing" an activity.
Independent nursing activities require documented evidence in which medical orders or instructions are linked to nursing activities that require a special "medical program" for the treatment given, treatment, procedure, other tests/examinations, hospital admission, referral or discharge of clients. .
Interdependent documentation activities:
Examples of medical programs or other health team recommendations, the nurse must document include: vital signs, suctioning of secretions, tracheostomy care, positioning, information from cardiac recordings, pacemaker, support, administration of enemas, treatment of irritation or other interdependent activities. Creating a nursing plan incorporates a description of activities or procedures that complement or are not responsive to the client. Documentation of incoming patients and discharge plans is carried out according to the doctor's program.
4. Standards of Responsibility for the Nursing Profession
Determination of a standard and implementation guidelines and standards of nursing documentation is a function of a nursing organization. A profession, if it has set a standard, indicates a commitment to the application of consistent action in the "problem solving" process.
The nurse has a certain expertise to identify, interpret, provide recommendations, and validate a useful standard. It is very appropriate that the nursing profession, in collaboration with other health professionals, has an important role in determining a standard of nursing.
The responsibility of the nursing profession in nursing documentation includes:
1. Using standards for recording and storage
2. Provide input as a “code”
3. Use the discretion of the nursing staff for record keeping.
4. Carry out activities related to nursing practice and the multi-disciplinary nursing profession.
5. Prioritize client problems and needs.
6. Fulfilling group requests; accreditation team and users/community
5. Standards Compiled by Health Services
The documentation standard on the front is the summary of records based on the health service institution. These standards include policies, procedures and implementation of standards as well as criteria for qualifying written statements. If the policy has been written to the staff, then all documentation must refer to that standard. The contents of policies and procedures include general and specific guidelines expected in the documentation. These expectations include:
a. Fill in each data entry, including date, time, legal aspect, title and individual/nurse identification.
b. Agreed use of abbreviations and symbols.
c. Correction procedure if there is an error.
d. The person authorized to enter data on client records.
e. Procedure for documentation correction.
f. Procedure for recording verbal commands
g. Recording date
h. Access to client records
i. Use of standard forms
j. Procedure for recording treatment actions.
Examples of Differences in Standard Policies and Procedures:
Policy Standards:
The nurse will write down the treatment measures and will sign in the space provided.
Standard Procedure :
If there is an error, it must be marked by crossing out the wrong word, then writing the correct word.
(Berman Snyder, Kozier, B. Erb, 2010)
saya hanya seorang individu yang sedang memahami arti dari sebuah kehidupan, belajar akan manis dan pahitnya dunia dan merasakan arti dari sebuah keluarga dan sahabat tentunya seorang kekasih yang kelak akan jadi ibu dari anak-anak saya.
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