tugas proses dan dokumentasi keperawatan fix

8/17/2019 Tugas Proses Dan Dokumentasi Keperawatan Fix

1/16

TUGAS PROSES DAN DOKUMENTASI KEPERAWATAN

KONSEP DASAR DOKUMENTASI KEPERAWATAN

DISUSUN OLEH:

Kelompok: 1

1) Ni Kadek Ari a!"#"i P$%1&$&1'$$%

&) P#"# Eprilia(i P$%1&$&1'$1$

) I G#!"i A # *i(" a Adia("i P$%1&$&1'$1&

') Ni P#"# No+ia I(da, Le!"ari P$%1&$&1'$1-

.) Kadek Po(i Mar/a a("i P$%1&$&1'$&-

DI0 KEPERAWATAN

TINGKAT 1 SEMESTER II

KEMENTERIAN KESEHATAN RI

POLITEKNIK KESEHATAN DENPASAR

TAHUN 2015

KATA PENGANTAR


2/16

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kepera6a"a(7 Dalam pe( #!#(a( kar a "#li! i(i pe(#li! 4a( ak me(dapa"ka( 4a("#a( dari

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ma(9aa" 4a2i ki"a !em#a7

De(pa!ar3 & April &$1.

Pe(#li!

Halama( 1


3/16

DAFTAR ISI

Halama(

HALAMAN ;UDUL 77777777777777777777777777777777777777777777777777777777777777777777777777

KATA PENGANTAR 7777777777777777777777777777777777777777777777777777777777777777777777777

DA>>>>>>>>>>>>>>>>777777

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17& R#m#!a( Ma!ala, 777777777777777777777777777777777777777777777777777777777777777717 T#/#a( Pe(#li!a( 77777777777777777777777777777777777777777777777777777777777777777

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&7 7 Ma(9aa" da( Pe("i(2( a Dok#me("a!i Kepera6a"a(777777777777

=A= III PENUTUP777777777777777777777777777777777777777777777777777777777777777777777777777

71 Simp#la(77777777777777777777777777777777777777777777777777777777777777777777777

DA


4/16

BAB I

Pendahuluan

1 1 La!a" Bela#an$

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memp#( ai pera(( a a(2 8#k#p 4e!ar dalam ma(a2eme( pe( impa(a( i(9orma!i da(

da"a di #(i"5#(i" pela a(a( ke!e,a"a( "er#"ama di R#ma, Saki" 7 *a"a"a( "e("a(2 i(9orma!i

pa!ie( mer#paka( ala" kom#(ika!i #("#k pro9e!!io(al di4ida(2 ke!e,a"a(7 Pe(i(2ka"a( ak!e!

"er,adap i(9orma!i dalam 4ida(2 ke!e,a"a( #("#k ma!i(2 i("erdi!iplier ?pro9e!i ke!e,a"a()

di,arapka( dapa" me(i(2ka"ka( k#ali"a! da( kela(2!#(2a( pera6a"a( pa!ie( !er"a

pe(2o4a"a(( a . Hal i(i /#2a me(2a("i!ipa!i 4a,6a dok#me("a!i kepera6a"a( dalam

8a"a"a( pa!ie( elek"ro(ik ?EPR) aka( me(/adi ala" 4eker/a pera6a" a(2 mem4erika(

i(9orma!i a(2 ak#ra" da( memadai "e("a(2 mereka pa!ie(7

Dok#me("a!i a!#,a( dalam pela a(a( kepera6a"a( adala, 4a2ia( dari ke2ia"a( a(2

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mer#paka( !#a"# i(9orma!i le(2kap melip#"i !"a"#! ke!e,a"a( pa!e(3 ke4#"#,a(

pa!e(3 ke2ia"a( a!#,a( kepera6a"a(@ke4ida(a( !er"a re!po(! pa!e( "er,adap a!#,a(

a(2 di"erima( a7*a"a"a( pa!ie( mer#paka( !#a"# dok#me( a(2 le2al3 dari !"a"#! !e,a" !aki" pa!e( pada

!aa" lampa#3 !ekara(23 dalam 4e("#k "#li!a(3 a(2 me(22am4arka( a!#,a( kepera6a"a(@

ke4ida(a( a(2 di4erika(7 Um#m( a 8a"a"a( pa!ie( 4eri!i im9orma!i a(2 me(2ide("i9ika!i

ma!ala,3 dia2(o!a kepera6a"a( da( medik3 re!po(! pa!e( "er,adap a!#,a(

kepera6a"a( a(2 di4erika( da( re!po(! "er,adap pe(2o4a"a( !er"a 4eri!i 4e4erapa re(8a(a

Halama(


5/16

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lapora( aka( !a(2a" mem4a("# kom#(ika!i a("ara !e!ama pera6a"@ 4ida( ma#p#( di!ipli(

ilm# lai( dalam re(8a(a pe(2o4a"a(7

1 2 Ru%u&an Ma&alah

17 Apaka, pe(2er"ia( dari dok#me("a!i kepera6a"a(

&7 Apaka, "#/#a( dari pem4#a"a( dok#me("a!i kepera6a"a(

7 Apaka, ma(9aa" da( pe("i(2( a dok#me("a!i kepera6a"a(

1 ' Tu(uan Penul)&an

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kepera6a"a(7

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kepera6a"a(7

1 * Man+aa! Penul)&an

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kepera6a"a( me(2e(ai model dok#me("a!i kepera6a"a( !e,i(22a ma,a!i!6a mamp#

Halama( '


6/16

me(erapka(( a dalam prak"ik !e,ari5,ari da( 4ia! mem4#a" dok#me("a!i kepera6a"a(

de(2a( 4aik !e,i(22a dapa" me(i(2ka"ka( k#ali"a! pela a(a( ke!e,a"a(7

Halama( .


7/16

BAB II

Pe%,aha&an

2 1 Pen$e"!)an D-#u%en!a&) Ke.e"a/a!an

Me(#r#" De!6a(i ?&$11) dok#me("a!i adala, !e!#a"# a(2 di"#li! a"a#

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perkem4a(2a( ko(di!i klie( !er"a !em#a ke2ia"a( a!#,a( kepera6a"a( a(2

dilak#ka( ole, pera6a" ?


8/16

mem4erika( a!#,a( kepera6a"a(7

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pada klie( mem4#"#,ka( 8a"a"a( da( pelapora( a(2 dapa" di2#(aka(

!e4a2ai "a(22#(2 /a6a4 da( "a(22#(2 2#2a" dari 4er4a2ai kem#(2ki(a(

ma!ala, a(2 dialami klie( 4aik ma!ala, kep#a!a( ma#p#( ke"idakp#a!a(

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me(e("#ka( kee9ek"i9a( pera6a"a( da( #("#k mem4a("# me( #!#( priori"a!

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pe(2o4a"a( da( e+al#a!i7 ?I er3 &$$')7

Seme("ara ANA dalam I er ?&$$') me(eka(ka( pera( dok#me("a!i

Halama( %


9/16

de(2a( per a"aa( 4a,6a pera6a" 4er"a(22#(2 /a6a4 #("#k

me(2#mp#lka( da"a da( me(2ka/i !"a"#! ke!e,a"a( klie(C me(e("#ka( re(8a(a

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me(2e+al#a!i e9ek"i+i"a! a!#,a( kepera6a"a( dalam me(8apai "#/#a( pera6a"a(C

da( me(2ka/i #la(2 !er"a mere+i!i kem4ali re(8a(a a!#,a( kepera6a"a(7

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me( ampaika( i(9orma!i kepada ora(2 lai( 7

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!er"a !em#a ke2ia"a( a!#,a( kepera6a"a( a(2 dilak#ka( ole, pera6a"

?


10/16

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ai"# :

a7 Se4a2ai !ara(a kom#(ika!i : dok#me("a!i a(2 dikom#(ika!ika( !e8ara ak#ra"

da( le(2kapdapa" 4er2#(a #("#k mem4a("# koordi(a!i a!#,a( kepera6a"a(

a(2 di4erika( ole, "im ke!e,a"a(3 me(8e2a, i(9orma!i a(2 4er#la(2

"er,adap pa!ie( a"a# a(22o"a "im ke!e,a"a( a"a# me(8e2a, "#mpa(2

"i(di,3 4a,ka( !ama !ekali "idak dilak#ka( #("#k me(2#ra(2i ke!ala,a( da(

me(i(2ka"ka( ke"eli"ia( dalam mem4erika( a!#,a( kepera6a"a( pada

pa!ie(3 mem4a("# "im pera6a" dalam me(22#(aka( 6ak"# !e4aik54aik( a7

47 Se4a2ai Ta(22#(2 ;a6a4 da( Ta(22#(2 G#2a" : !e4a2ai #pa a #("#k

meli(d#(2i klie( "er,adap k#alli"a! pela a(a( kepera6a"a( a(2

di"erima da( perli(d#(2a( "er,adap keama(a( pera6a" dalam

melak!a(aka( "#2a!( a maka pera6a" di,ar#!ka( me(8a"a" !e2ala

"i(daka( a(2 dilak#ka( "er,adap klie(7

87 Se4a2ai I(9orma!i S"a"i!"ik : da"a !"a"i!"ik dari dok#me("a!i

kepera6a"a( dapa" mem4a("# mere(8a(aka( ke4#"#,a( di ma!a

me(da"a(23 4aik SDM3 !ara(a3 pra!ara(a da( "ek(i!7

d7 Se4a2ai Sara(a Pe(didika( : dok#me("a!i a!#,a( kepera6a"a( a(2

dilak!a(aka( !e8ara 4aik da( 4e(ar aka( mem4a("# para !i!6a

kepera6a"a( ma#p#( !i!6a ke!e,a"a( lai(( a dalam pro!e! 4ela/ar

me(2a/ar #("#k me(dapa"ka( pe(2e"a,#a( da( mem4a(di(2ka(( a3 4aik

"eori ma#p#( prak"ik lapa(2a(7

Halama( B


11/16

e7 Se4a2ai S#m4er Da"a Pe(eli"ia( : i(9orma!i a(2 di"#li! dalam dok#me("a!i

dapa" di2#(aka( !e4a2ai !#m4er da"a pe(eli"ia(7 Hal i(i !ara" kai"a(( a de(2a(

a(2 dilak#ka( "er,adap a!#,a( kepera6a"a( a(2 di4erika( !e,i(22a melal#i

pe(eli"ia( dapa" di8ip"aka( !a"# 4e("#k pela a(a( kepera6a"a( a(2 ama(3 e9ek"i9

da( e"i!7

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dapa" di8apai3 kare(a /ami(a( k#ali"a! mer#paka( 4a2ia( dari pro2ram pe(2em4a(2a( pela a(a( ke!e,a"a(7 S#a"# per4aika( "idak dapa" di6#/#dka(

"a(pa dok#me("a!i a(2 ko("i(#3 ak#ra"3 da( r#"i( 4aik a(2 dilak#ka( ole,

pera6a" ma#p#( "e(a2a ke!e,a"a( lai(( a7

27 Se4a2ai S#m4er Da"a Pere(8a(aa( A!#,a( Kepera6a"a( =erkela(/#"a( : de(2a(

dok#me("a!i aka( didapa"ka( da"a a(2 ak"#al da( ko(!i!"e( me(8ak#p !el#r#,

ke2ia"a( kepera6a"a( a(2 dilak#ka( melal#i "a,apa( ke2ia"a( pro!e!

kepera6a"a(7

2 ' Man+aa! dan Pen!)n$n0a D-#u%en!a&) Ke.e"a/a!an

Dok#me("a!i a!#,a( kepera6a"a( mer#paka( "#("#"a( pro9e!i a(2 ,ar#!

dapa" diper"a(22#(2/a6a4ka(3 4aik dari a!pek e"ik ma#p#( a!pek ,#k#m7

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diper"a(22#(2/a6a4ka( dari ked#a a!pek i(i 4erkai"a( era" de(2a( a!pek

ma(a/erial3 a(2 di!a"# !i!i meli(d#(2i pa!ie( !e4a2ai pe(erima pela a(a(

Halama( 1$


12/16

?ko(!#me() da( di!i!i lai( meli(d#(2i pera6a" !e4a2ai pem4eri /a!a

pela a(a( da( a!#,a( kepera6a"a( ?Hida a"3 &$$&)

N#r!alam ?&$11) me(era(2ka( 4a,6a dok#me("a!i kepera6a"a(

memp#( ai mak(a a(2 pe("i(2 dili,a" dari 4er4a2ai a!pek !eper"i a!pek

,#k#m3 k#ali"a! pela a(a(3 kom#(ika!i3 ke#a(2a(3 pe(didika(3 pe(eli"ia(3

da( akredi"a!i7 Pe(/ela!a( me(2e(ai a!pek5a!pek "er!e4#" adala, !e4a2ai

4erik#":

a7 H#k#m

Sem#a 8a"a"a( i(9orma!i "e("a(2 klie( mer#paka( dok#me("a!i re!mi da(

4er(ilai ,#k#m7 =ila me(/adi !#a"# ma!ala, ?misconduct ) a(2

4er,#4#(2a( de(2a( pro9e!i kepera6a"a(3 di ma(a !e4a2ai pem4eri /a!a da(

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!e6ak"#56ak"#7 Dok#me("a!i "er!e4#" dapa" diper2#(aka( !e4a2ai 4ara(2 4#k"i

di pe(2adila(7

47 K#ali"a! Pela a(a(

Pe(dok#me("a!ia( da"a klie( a(2 le(2kap da( ak#ra"3 aka( mem4eri

kem#da,a( 4a2i pera6a" dalam mem4a("# me( ele!aika( ma!ala, klie(7

Da( #("#k me(2e"a,#i !e/a#, ma(a ma!ala, klie( dapa" "era"a!i da( !e4erapa /a#,

ma!ala,dapa" diide("i9ika!i da( dimo(i"or melal#i dok#me("a!i a(2 ak#ra"7 Hal i(iaka( mem4a("# me(i(2ka"ka( k#ali"a! ?m#"#) pela a(a( kepera6a"a(7

87 Kom#(ika!i

Dok#me("a!i keadaa( klie( mer#paka( ala" perekamF "er,adap

Halama( 11


13/16

ma!ala, a(2 4erkai"a( de(2a( klie(7 Pera6a" a"a# pro9e!i ke!e,a"a( lai(

dapa" meli,a" dok#me("a!i a(2 ada da( !e4a2ai ala" kom#(ika!i a(2 di/adika(

pedoma( dalam mem4erika( a!#,a( kepera6a"a(7

d7 Ke#a(2a(

Dok#me("a!i dapa" 4er(ilai ke#a(2a(7 Sem#a a!#,a( kepera6a"a(

a(2 4el#m3 !eda(23 da( "ela, di4erika( didok#me("a!ika( de(2a(

le(2kap da( dapa" diper2#(aka( !e4a2ai a8#a( a"a# per"im4a(2a( dalam 4ia a

kepera6a"a( 4a2i klie(7

e7 Pe(didika(

Dok#me("a!i memp#( ai (ilai pe(didika(3 kare(a i!i( a me( a(2k#"

kro(olo2i! dari ke2ia"a( a!#,a( kepera6a"a( a(2 dapa" diper2#(aka( !e4a2ai

4a,a( a"a# re9ere(!i pem4ela/ara( 4a2i pe!er"a didik a"a# pro9e!i kepera6a"a(7

97 Pe(eli"ia(

Dok#me("a!i kepera6a"a( memp#( ai (ilai pe(eli"ia(7 Da"a a(2 "erdapa"didalam( a me(2a(d#(2 i(9orma!i a(2 dapa" di/adika( !e4a2ai 4a,a( a"a#

o4/ek ri!e" da( pe(2em4a(2a( pro9e!i kepera6a"a(7

27 Akredi"a!i

Melal#i dok#me("a!i kepera6a"a( aka( dapa" dili,a" !e/a#, ma(a pera(

da( 9#(2!i pera6a" dalam mem4erika( a!#,a( kepera6a"a( kepada klie(7 De(2a(

demikia( dapa" diam4il ke!imp#la( me(2e(ai "i(2ka" ke4er,a!ila( pem4eria(

a!#,a( kepera6a"a( a(2 di4erika( 2#(a pem4i(aa( da( pe(2em4a(2a(

le4i, la(/#"7

Halama( 1&


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Halama( 1


15/16

Ba, III

Penu!u.

' 1 S)%.ulan

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Halama( 1'


16/16

Da+!a" Pu&!a#a

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