DAFTAR ISI

HALAMAN JUDUL.........................................................................................................i

KATA PENGANTAR......................................................................................................ii

DAFTAR ISI....................................................................................................................iii

BAB I PENDAHULUAN

LATAR BELAKANG MASALAH.................................................................................1

TUJUAN MASALAH......................................................................................................2

BAB II PEMBAHASAN

PENDOKUMENTASIAN ASUHAN KEPERAWATAN ............................................3

ELECTRONIC PATIENT RECORD..............................................................................6

PENDOKUUMENTASIAN DENGAN EPR .................................................................8

GAMBARANN PERENCANAAN ...............................................................................10

DOKUMENTASI TINDAKAN KEPERAWATAAN ..................................................10

TUJUAN INTERVENSI, DAN NIC ..............................................................................11

INTERVENSI NOC........................................................................................................13

DIAGNOSA / MASALAH KOLOBORASI RENCANA KEPERAWATAN ............. 17

PATOKAN DOKUMENTASI KEPERAWATAN ..................................................... 29

PRINSIP PENCATATAN DOKUMENTASI ...............................................................37

BAB III PENUTUP

SIMPULAN.....................................................................................................................39

SARAN............................................................................................................................39

DAFTAR PUSTAKA......................................................................................................40