DOKUMENTASI KEPERAWATAN

OLEH :

TASYA NAILA AZZAHRA (1030191065)

WIDYA NURARIFIN (1030191069)
RADIKA GITA (1030191052)
RICCA CLARASHINTA (1030181058)
 Definisi

Dokumentasi merupakan segala sesuatu yang ditulis

atau dicetak , yang dapat dipercaya sebagai bukti
kewenangan individu (Edelstein, 1990). Sedangkan
proses keperawatan adalah metoda sistematis yang
mengarahkan klien dan perawat untuk bersama-sama
menetapkan kebutuhan terhadap asuhan,
merencanakan dan melaksanakan asuhan, serta
mengevaluasi hasil asuhan.
PROSES DOKUMENTASI KEPERAWATAN

1.Dokumentasi pengkajian keperawatan

2.Dokumentasi diagnosa keperawatan
3.Dokumentasi rencana keperawatan
4.Dokumentasi tindakan keperawatan
5.Dokumentasi evaluasi keperawatan
1.Pendokumentasian pengkajian keperawatan

Pengkajian adalah pemikiran dasar dari proses keperawatan yang bertujuan

untuk mengumpulkan informasi atau data tentang klien, agar dapat
mengidentifikasi, mengenali masalah-masalah, kebutuhan kesehatan dan
keperawatan klien, baik fisik, mental, sosial dan lingkungan (Effendy, 1995).

Data Dasar dan Data Fokus

•Data dasar
Kumpulan data mengenai status kesehatan klien, kemampuan klien untuk
mengelola kesehatan dan keperawatannya terhadap dirinya sendiri, dan hasil
konsultai medis (terapist) atau profesi kesehatan lainnya (Taylor, Lillis & Le
Mone, 1996)

•Data fokus
Data tentang perubahan-perubahan atau respon klien terhadap kesehatan, dan
masalah kesehatannya, serta hal-hal yang mencakup tindakan yang
dilaksanankan pada klien.
Pengumpulan Data

1.Subyektif
•Didapat melalui interaksi dan komunikasi dengan klien (persepsi, perasaan, ide klien tentang status
kesehatan) misalnya: penjelasan klien tentang nyeri, lemah, mual dll
•Informasi oleh sumber lain (keluarga, konsultan, & tenaga kesehatan lain juga sebagai data
subyektif jika berdasar pendapat klien)
2.Obyektif
•Data yang dapat diobservasi dan diukur
•From sense (sight, smell), HT (hearing and touch or taste)
•Fokus pengumpulan data meliputi :
1.Status kesehatan sebelum / sekarang
2.Pola koping sebelum dan sekarang
3.Respon terhadap terapi medis dan tindakan keperawatan
4.Resiko untuk masalah potensial
5.Hal-hal yang menjadi dorongan atau kekuatan klien
Sumber Data (Nur Salam, 2001)
Lanjutan
1. Klien ; merupakan sumber data klien
2. Orang terdekat
3. Catatan klien
4. Riwayat penyakit
5. Konsultasi (dengan terapist / tim kesh lain)
6. Hasil pemeriksaan diagnostik
7. Catatan medis dan anggota tim kesehatan lain
8. Perawat lain
9. Kepustakaan
Jenis Dokumentasi Pengkajian

1.Pengkajian awal (Initial Assesment)

•Dilaksanakan ketika klien MRS
•Bentuk merujuk pada data dasar perawatan

2.Pengkajian Kontinyu (Ongoing Assesment)

•Merupakan pengembangan data dasar
•Informasi yang diperoleh dari klien selama pengkajian awal dan informasi tambahan (tes diagnostik, dan
sumber lain); diperlukan untuk menegakkan data

3.Pengkajian Ulang (Reassesment)

•Data yang didapat selama evaluasi
•Pengkajian ulang; perawat mengevaluasi kemajuan data dari masalah klien atau mengembangkan data
dasar; sebagai informasi tambahan
Bentuk Format Dokumentasi
•Tanya jawab
•Daftar periksa (memerlukan jawaban ya/tidak)
•Format quisioner (banyak digunakan di rawat jalan)

Metode Dokumentasi Pengkajian

Bentuk dokumentasi dapat berupa data dasar, lembar alur (flowsheet) dan catatan perkembangan.Untuk
mendapatkan catatan pengkajian aktual maka perlu pedoman,
antara lain: 1.gunakan format yang terorganisasi
2.gunakan format yang telah ada
3.format mencakup pemeriksaan head to toe
4.catat informasi yang akurat tanpa opini2 pribadi
5.mesukkan pernyataan yang mendukung klien
6.jabarkan observasi dan hasil dengan jelas
7.tulis data secara ringkas
 2. Pendokumentasian diagnosa keperawatan

Pengertian Diagnosa Keperawatan : •Keputusan klinis mengenai seseorang, keluarga, atau

masyarakat sebagai akibat dari masalah kesehatan, atau
proses kehidupan yang aktual potensial
•Catatan tentang penilaian klinis dari respon individu, keluarga
atau komunitas terhadap masalah kesehatan atau proses
kehidupan baik aktual / potensial.
Kategori Diagnosa Keperawatan (Carpenito,2000)

1.Resiko / Resiko Tinggi

•Keputusan klinis tentang individu, keluarga, masyarakat yang sangat rentan untuk mengalami
masalah dibanding individu / kelompok lain pada situasi yang sama atau hampir sama.
•Mengganti istilah diagnosa keperawatan potensial, dengan menggunakan resiko terhadap atau
resiko tinggi terhadap
•Validasikan faktor2 resiko yang menunjukkan keadaan kerentanan yang meningkat terhadap
klien, kelompok dan tidak menggunakan batasan karakteristik
•Rumusan : P E (Problem ; Etiologi)
Lanjutan
2.Kemungkinan
Pernyataan tentang masalah yang diduga masih memerlukan data
tambahan dengan harapan diperlukan untuk memastikan adanya
tanda dan gejala utama adanya faktor risiko

Contoh: Kemungkinan gangguan konsep diri berhubungan dengan

ehilangan peran tanggung jawab
3.Sejahtera / Wellness 4.Sindroma
Ketentuan klinis mengenai individu, keluarga, masyarakat dalam Diagnosa keperawatan yang terdiri atas kelompok diagnosa
transisi dari tingkat kesehatan khusu ke tingkat kesehatan aktual atau resiko tinggi yang diduga akan muncul karena
yang lebih baik suatu kejadian atau situasi tertentu.
•Contoh: Sindroma disuse yang berhubungan dengan
•Cara: menggabungkan pernyataan fungsi positif dalam masing- tindakan pembedahan (amputasi).
masing pola kesehatan fungsional sebagai alat pengkajian yang
disyahkan
•Contoh: Perilaku mencari bantuan kesehatan yang berhubungan
dengan meningkatnya pengetahuan tentang pentingnya
kesehatan
Tujuan Penulisan Dokumentasi Keperawatan

•Mengkomunikasikan masalah klien dengan tim kesehatan

•Mendemonstrasikan tanggung jawab dalam identifikasi masalah
klien
•Mengidentifijasi masalah utama untuk perkembangan intervensi
keperawatan
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