WS IMPLEMENTASI PARADIGMA PELAYANAN BERFOKUS PADA

PASIEN
PCC

Asesmen Awal
Pengisian CPPT
oleh DPJP

Dr. Nico A. Lumenta, K.Nefro, MM, MHKes.

KARS
 Proses Asuhan Pasien
2 blok Patient Care
1 kegiatan

Asesmen Pasien Pola IAR

(Skrining, Periksa Pasien)
Profesinal Pemberi Asuhan

S 1. Informasi dikumpulkan : Anamnesa,

Asesmen Ulang
pemeriksaan, pemeriksaan lain / penunjang,
O dsb
(IA
A 2. Analisis informasi : dihasilkan R)
Diagnosis / Problem / Kondisi,
(PPA)

identifikasi Kebutuhan Yan Pasien

P 3. Rencana Pelayanan/Care Plan disusun :
untuk memenuhi Kebutuhan Yan
Pasien

*Implementasi Rencana
Pemberian Pelayanan
*Monitoring
 Proses Asuhan Pasien
2 blok proses, oleh masing2 PPA

1. Asesmen Pasien IAR

S 1. INFORMASI DIKUMPULKAN: anamnesa, I

Std AP 1
pemeriksaan fisik, pemeriksaan lain / penunjang, dsb
O
2. ANALISIS INFORMASI : menghasilkan kesimpulan Std APK 1, 1.1.1,
a.l. Masalah, Kondisi, Diagnosis, 1.1.2, 3, 4, AP
untuk mengidentifikasi kebutuhan pelayanan pasien A 1.3, 1.3.1, 1.2. EP
A 4, 1.9, 1.11, 4.1,
PP 7.
RENCANA PELAYANAN / Care Plan , R Std PP 2 EP 1, PP
P 3. MEMBUAT
untuk memenuhi kebutuhan pelayanan pasien 2.1, 5, Std AP 2,
PAB 5, 7, 7.4.
2. Implementasi Rencana Std PP 2, EP 2,
PP 5 EP 2 & 3,
Pemberian Pelayanan PAB 3 EP 5, 5.3,
Monitoring 6, 7.3,
3
Pemberian pelayanan/asuhan, pelaksanaan rencana, beserta monitoringnya
Beberapa metode pencatatan asesmen

SOAP : Subjective, Objective, Assessment,

Plan
ADIME : Assessment, Diagnosis,
Intervention (+ Goals), Monitoring,
Evaluation
DART : Description, Assessment,
Response, Treatment
Proses Asuhan Pasien
Patient Care

Asesmen Awal
Medis Perawat (Dietisian)

Asesmen Ulang
Medis Perawat PPA
Lainnya

5
 Form Asesmen Awal
Medis Perawat (Dietisian)

I Informasi : Anamnesa, Pemeriksaan fisik, Pemeriksaan

Penunjang, Pemeriksaan lain
A Analisis (Asesmen) : Diagnosa, Masalah, Kondisi : utk
identifikasi Kebutuhan Yan Pasien
R Rencana : Rencana obat, tindakan, pemeriksaan lain : utk
memenuhi Kebutuhan Yan Pasien

Isi Form Asesmen Awal

(Isi minimal form, dapat perdisiplin)
IGD Triage IAR & Pemberian Yan
I Riwayat kesehatan, Pemeriksaan fisik.
Psikologis, Sosio-ekonomis, Nyeri, Risiko
I
A jatuh, Risiko nutrisional
Rajal Diagnosis awal, Masalah, Kondisi A
Rencana Tindakan, Obat,
R KARS
R
 s m e n IGD
As e

1/4 KARS, Nico A. Lumenta 7

 Ase
sm
en
IGD

2/4 KARS, Nico A. Lumenta 8

 A se
sm
en
IGD

IA
R

3/4 KARS, Nico A. Lumenta 9

 Ase
sme
n IG
D
IA
R

4/4 KARS, Nico A. Lumenta 10

Asesmen IGD

1/2

(DIISI OLEH PERAWAT)

(DIISI OLEH PERAWAT)

IA
R

KARS, Nico A. Lumenta 11

 (DIISI OLEH DOKTER)

Asesmen IGD
2/2
(DIISI OLEH PERAWAT)
(DIISI OLEH PERAWAT)

IA
R

KARS, Nico A. Lumenta 12

Asesmen Awal Medis-1/2

KARS, Nico A. Lumenta 13

Asesmen Awal Medis-2/2

IA
R

KARS, Nico A. Lumenta 14

 Asesmen Awal Pwt-1/6

KARS, Nico A. Lumenta 15

 Asesmen Awal Pwt-2/6

KARS, Nico A. Lumenta 16

 Asesmen Awal Pwt-3/6

Lanjut Pengkajian
Nyeri Komprehensif

KARS, Nico A. Lumenta 17

 Asesmen Awal Pwt-4/6

KARS, Nico A. Lumenta 18

 Asesmen Awal Pwt-5/6

KARS, Nico A. Lumenta 19

 Asesmen Awal Pwt-6/6

KARS, Nico A. Lumenta 20

Asesmen Rawat Jalan h. 1/2 h. 2/2

IA
R

KARS Nico A. Lumenta

 T
CPP Catatan Perkembangan Pasien Terintegrasi
Nama Pasien :

Tangga (Tepi utk) (Tepi utk) Nama

l Dokter Staf Klinis lainnya Ttd
Jam
S aaaa bbbbb ccccc hhhhhh vvvvvvv nbnnnnnn bbbbbbbbbb ..
10/5/13
O ddd eeee ..
7.30
A ggggg hhhhh kkkkk
P nnnn pppppp qqqqq Prwt..
8.15 S ccccc hhhhh ccccc hhhhhh vvvvvvv nbnnnnnn bbbbbbbbbb kkkkkkkkkk..
O ddd eeee ..
A ggggg hhhhh kkkkk
P nnnn pppppp qqqqq jjjjjjjjjjjj oooooooooooo pppppppp Dr..
9.10
S Ttttt fffff ppppp kkkkkk yyyyyy
O Eee ddddd xxxxx
A Aaaaa mmmmm dddd uuuuuuu aaaaaaaa dddddd rrrr ccc. Ahli
P Rrrrr llll hhhh wwww Gizi..
Dst

(Semua PPA (Profesional Pemberi Asuhan) mencatat perkembangan pasien disini,

semua PPA membaca semua catatan) KARS, Nico A. Lumenta 22
 T
CPP

KARS, Nico A. Lumenta 23

 T
CPP

DPJ
Clin P
ical
Lead
e r

KARS Dr.Nico Lumenta

 Catatan Perkembangan Pasien Terintegrasi - CPPT

Asesmen ulang dicatat di CPPT

Asesmen ulang terjadi di Ranap, tetapi dapat juga di IGD,
Rajal
Pelaku : Semua Nakes PPA terkait
Untuk Perawat dicatat tentang Progress pasien. Nurses
note dicatat dalam form lain
Pencatatan Asesmen ulang dgn metode SOAP : Subjective,
Objective, Assessment, Plan.
Untuk Gizi dgn ADIME : Assessment, Diagnosis,
Intervention (+ Goals), Monitoring, Evaluation
RS agar menetapkan Form-form lain yang diperlukan sesuai
kebutuhan

25
 Catatan Perkembangan Pasien Terintegrasi - CPPT
Subjective
Initiate an interview with the patient.
Ask how old issues are coming along and whether there are any new
complaints.
Seek details. Ask questions such as: When does it happen? How
does it feel? What did you do? How many times? Where does it hurt?
Ask what other medical practitioners the patient has seen.
Ask what the other doctors or nurses have told him.
Find out what is new or has changed in the patient's life. Ask how it is
affecting her health and state of mind.

"OLD CHARTS" :
Onset, Location, Duration, CHaracter (sharp, dull, etc.),
Alleviating/Aggravating factors, Radiation, Temporal pattern
(every morning, all day, etc.), Severity
The SOAP note was first generated by Dr. Lawrence Weed, MD in the 1970s, under the
acronym POMR (Problem Oriented Medical Record).
26
 Catatan Perkembangan Pasien Terintegrasi - CPPT
Objective
Obtain objective information by observation and testing. The data will
be a record of what you observe and what the tests show.
Begin with the patient's vital signs: height, weight, blood pressure,
pulse, temperature.
Conduct a basic physical exam, from general appearance to reflexes,
and note anything that has changed from the previous visit.
Add any new hard data, such as laboratory results, to the patient's
record.
The objective section of the SOAP includes information that the
healthcare provider observes or measures from the patient's current
presentation. The objective component includes:
Vital signs and measurements, such as weight.
Findings from physical examinations, including basic systems of
cardiac and respiratory, the affected systems, possible involvement of
other systems, pertinent normal findings and abnormalities.
Results from laboratory and other diagnostic tests already completed.
Medication list obtained from pharmacy or medical records.
27
 Catatan Perkembangan Pasien Terintegrasi - CPPT

Assessment
Evaluate the information you have obtained.
Make a diagnosis, or record what you suspect.
Summarize or even list ongoing problems with the
patient's current status -- stable, progressing, improved,
resolved and so on -- and any new complaints.
Plan
Record what you intend to do with the information you
have obtained. Include medication changes -- started,
discontinued, increased, decreased -- and referrals to
specialists, tests ordered, recommendations and
instructions to the patient.
State when or if the patient should return for follow-up
KARS : Tulis Sasaran terukur yang ingin dicapai (Std PP
2.1.) 28
 MANAGEMENT AND OBSERVATION CHARTS
1. Pain Management and Evaluation Chart
2. Pain Management and Evaluation Graph
3. *Residential Care Services Wound Progress Chart
4. Oral Hygiene Management Plan (OHCP)
5. Resident Serial Weight Chart
6. *Falls Risk Assessment Management Chart (FRAT) (part of the
assessment tool)
7. *Falls Risk Assessment and Management Form (CERA)
8. *Ballarat Urinary Management Form, refer to tool
9. 24 hr Urinary Diary and Observation Chart
10. *Ballarat Bowel Management Form
11. Ballarat Bowel Observation Chart
12. Behavioural Management Chart
13. Vital Sign Observation Chart
14. Catheter and Line Management Chart 29
 DPJP dalam Patient Centered Care

DPJP
Perawat/ Ahli Gizi
Bidan

Fisio Psikolog
terapis Pasien, Klinis
Keluarga

Penata Apoteker
Anestesi
Lainnya

DPJP adalah Clinical/Team Leader PPA

Koordinasi
Kolaborasi
Sintesis
Interpretasi
Integrasi asuhan komprehensif
 Standar PP.1 Keseragaman Pelayanan
Standar PP.2 Integrasi asuhan integrasi asesmen
pasien IAR
Standar PP.2.1 Rencana Asuhan
1) Asesmen pasien (pola IAR) oleh masing2 Nakes PPA :
tugas mandiri, sifatnya individual, menghasilkan Rencana
2) Rencana asuhan memuat : rencana dan sasaran-terukur
3) Rencana asuhan dicatat dalam rekam medis dalam
bentuk kemajuan terukur pencapaian sasaran.
4) Rencana asuhan utk tiap pasien direview dan di verifikasi
oleh DPJP dengan memberikan catatan pd CPPT
Clinical Leader
Integrasi asuhan
5) Plan of Care Rencana terintegrasi
31
 Plan of
Ca
Std PP re
2.1

KARS, Nico A. Lumenta 32

 T
CPP

DPJ
Clin P
ical
Lead
e r

KARS Dr.Nico Lumenta

Dr. Nico A. Lumenta, K.Nefro, MM, MHKes
Komisi Akreditasi Rumah Sakit