The Integrated Patient Development Record in Type C Hospital Padang
Abstract
Documentation of patient progress notes integrated communication tools in the integrated care undertaken by professional caregivers in providing health services to patients. Incomplete documentation will form a framework that is not good that would aggravate the framework of the PPA, because of the necessary documentation to do with good professional practice of doctors, nurses, pharmacists and nutrisionist to avoid unexpected events (KTD), medication errors and error intervention. The purpose of this study was to compare the factors that most influence the PPA in the documentation of patient progress notes integrated (CPPT) in the Type C Inpatient Hospital Padang Year 2018 Type of research with cross sectional design. Sampling of this research is proportional random sampling with a sample of 157. Retrieving data using a
questionnaire. Data were analyzed using Chi Square, multiple logistic egression. Research conducted at three hospitals obtained completeness CPPT by 4 professional carer (PPA) is still found CPPT incomplete charging. CPPT charging incompleteness may result in unexpected events (KTD), medication errors and errors that intervention would be detrimental to the patient. Factors most associated with CPPT in the RS Type C Padang is knowledge in the RS
and RS X Y Z Machine while in the hospital. The most influential factor and machine knowledge, in charge of health personnel CPPT necessary knowledge that will improve the completeness CPPT thus the necessity of charging CPPT related education and RS Z should improve the infrastructure so that the CPPT better documentation and to avoid omissions in patient documentation.
Keywords
Full Text:
PDFReferences
Alimul Aziz. (2004). Introduction to Basic Concepts of Nursing. Jakarta: Salemba Medika.
Arikunto, S. (2006). Research Procedure A Practice Approach. Jakarta: Rineka Reserved.
Anggriani. 2017. Factors Contributing Incomplete Medical Records Inpatient Hospital
Waluya Griya Roxburgh. KTI STIKES Buana Husada Ponorogo
Asya, Ulul Azmi. 2017. Integrated Care Documentation Standards In Space Rinra Interna
Care Honey 2 In Hospital Haji Makassar. Thesis Faculty of Islamic
Keperawatan.Universitas. Makassar.
Basuki E. 2008. Communication Between Health Officer. Medical Indonesia. Indonesian
Medical Magazine. 58: 340-345.
Dinarti & Ratna Aryani. (2009). Nursing documentation. Jakarta Trans Media Info
Diyanto, Y. (2007). Analysis Factors Nursing Documentation Implementation In Rumash
Tugurejo Semarang General Hospital. Journal of Nursing Management. 1 (1), 1-6
Dahlan, MS (2014). Statistics for Medical and Health: Descriptive, Bivariate, and
Multivariate, Condition Application Using SPSS, 6ED. Epidemiology of Indonesia,
Jakarta.
Donabedian, A.2003. An Intruduction to Quality Assurance in Health Care. Oxford, Oxford
University Press
Estes B & Wang, J. (2013). Integrative Literature Review: Workplace Invicivility: Impacts
on Individual and Organizational Performance. Human Resource Development Review.
(2), 218-240
Frelita, G, Situmorang, TJ & Silitonga, DS 2011. Accreditasion Joint Commission
International Standards for Hospitals, 4th ed. Oakbrook Terrace, Illinois 60181 USA
Gustomi, MP (2015). The application of the model of nursing care documentation, 6
(November), 150-157.
Gillies. (2000). Nursing Management As An Approach System (Translation). Bandung:
Foundation IAPKP
Handoko, T Hani. (2012) Personnel management and human resources. Yogyakarta: BPFE
Hariyati, Tutik Sri. 2014. Development and Utilization Planning Nurses. Jakarta: Rajawali
Press
Hastono. SP (2007). Health Data Analysis. Jakarta: FKM UI
Hatta 2011. Guidelines for Health Information Management In Health Care Facilities.
Jakarta: UI Press
Herlambang, S & Muwarni A. 2012. Management of Health and Hospitals. Yogyakarta:
Goshen Publishing
Hidayat. (2011). Health research methods. Jakarta: Rineka Reserved
Huber, DL (2006). Leadership and Nursing Care Mangement. Of Philadelphia. Saunders
Elsevier.
Hutama, H., & Santosa, E. (2016). Quality Evaluation of Medical Records at 1 PKU
Muhammadiyah Hospital in Yogyakarta: A Case Study in Patients Sectio Caesaria, 5
(1), 25-34. http://doi.org/10.18196/jmmr.5103.
Ilmonen, Kaj. (2011). A Social And Economic Theory of comsumption. UK: Palgrave
Macmillan
JCI. 2006. Journal on Quality and Patient Safety, Root Causes of Sentinel Events.
The Commission on Accreditation of Hospitals. Doctors Peanggung 2015. Implementation
Guide FAQ Patients (DPJP)
MoH RI. (2009). Law Number 36 Year 2009 on Health. Jakarta: State Secretariat
MoH RI. (2011). Hospital Accreditation Standards, Cooperation Directorate General of
Republic of Indonesia Health Efforts by the Commission on Accreditation of Hospitals
(KARS). Jakarta
MoH RI. (2012). Indonesian Demographic and Health Survey. Jakarta
Khler, J, Hafner. Spelz, LM, Steen, S & Weaver, K. 2009. Implementation of Standarized
Nomenclature in the electronic medical record. int Jnurs.Terminol.Classif
Kuntoro, A. (2010). Textbook of Nursing Management. Yogyakarta: Nuha Medika
Kron. (1987). The Management of Patient Care Leadership Skill Putting Work. Sixth.
Edition: WB Saunders Company
Lasmani, PS, Haryanti, F., Blue, L., Kepewaratan, PI, Medicine, F., Mada, UG, Mada, UG
(2014). Evaluation Of Iintegrated Medical Record Implementasion Case Study In, 17
(1), 3-8.
Lasmani, Patricia Suti. 2013. Evaluation of the implementation of an integrated medical
record inpatient Hospital Yogyakarta DR.Sardjito
Linggardini, Kris. (2010). Supervision Relationship With The Computer Based
Documentation Perceived Executive Nurse Inpatient Hospital In Banyumas, Central
Java. Thesis Faculty of Nursing. University of Indonesia. Jakarta
Loedin, AA (2003). National Guidelines for Health Research Ethics. Jakarta: The National
Committee for Medical Research Ethics
Lumenta. (2015). Responsible Physician Implementation Guide Patient and Case Manager.
Jakarta: The Commission on Accreditation of Hospitals
Mc Eachen & Keogh. (2007). Nurse Management Demistyfied, A Self Teaching giude. New
York: The McGraw-Hill Companies
Martono, N. (2010). Qualitative Research Methods: Content Analysis and Secondary Data
Analysis. Jakarta: King Grafindo Persada
Marquis, BL (2010). Nursing Leadership and Management: Theory and Applications.
Jakarta: EGC
Marquis, BL & Huston, CJ 2001. Fuctiontions Leadership Roles and Management in
Nursing: Theory and Application (3rd Ed). Of Philadelphia. Lippincot Williams &
Wilks
Nasir A, Muhith A, Sajidin M, Mubarak WI. 2009. Communication Nursing: Theory and
Application. Jakarta: Salemba Medika
Notoadmodjo, S. 2010. Research Methodology Keshatan .. Ed. Rev. Jakarta: Rineka
Reserved
Nurman, M. 2013. Factors - Factors Associated With Nursing Documentation in patient
wards of hospitals Bangkinang, 19, 1-13.
Nursalam. 2008. Nursing Process and Documentation; Concepts and Practice (2nd ed.).
Jakarta: Salemba Medika.
Nursalam, 2012. Nursing Management Applications in Professional Nursing Practice. Issue
Jakarta: Jagakarsa
Personal, General. 2009. Influence Factor Analysis of Knowledge, motivation, and
perceptions about Supervising Head Nurse of Implementation Documentation Room
Nursing Inpatient Hospital In Space Kelet in Jepara, Central Java province. Thesis
Faculty of Public. Of University of Diponegoro. Semarang
Priyanto. 2011. The integrated documentation system innovation in intensive nursing care in
ICCU RSUPN Dr. Ciptomangunkusumo Jakarta.
Rakhmawati, W. 2009. Monitoring and Control In Nursing Services (Supervision, Quality &
Risk Management). Training in Nursing Management (pp. 11-16)
Medical records. 2018. RSI Siti Rahmah Padang
Medical records. RSI 2018. Ibn Sina (Yarsi) Padang
Medical records. RSB 2018. Ropanasuri Padang
Riyanto, Agus. 2010. Modules, Basic Data Analysis For Health Research Training. Conveyed
On the Training Data Processing and Data Analysis Health, Nursing Academy Setih
Setio in Muara Bungo, Jambi
Rizal, AAF, Chasani, S., and Warsito, BE (2016). Relationship Management Function
Implementation Chief Executive Lounge with Motivation Nurses in Providing Nursing
Service at the Hospital Inpatient Room of Semarang. Journal of Medical Sciences, 4 (1),
-6
Rosyidi, K. (2013). In the leadership Management Nursing. Jakarta: Trans Media Info
Rustiyanto, 2009. Professional Ethics of Medical Records and Health Information.
Yogyakarta: Graha Science
Sari, Rebbi gem. 2016. Analysis of Perception of Health Workers Against the Case Manager
and Production Function documentation Integrated Patient Progress Notes RuanganIrna
Non Surgical Hospital In Padang M.Djamil. Thesis Faculty of Nursing. University
Andalas.Padang
Setiowati, 2015. Relations Supervising Head room with Implementation Risk Patient Fall
Prevention guidelines. Journal of Medical Science Indonesia. 5 (2), 58-62
Shofari, Bambang. 2005. Management of Medical Record System. Perekammedisan
Association of Professional Organizations, Health Informatics Indonesia. Semarang
Siagian, 2014. Human Resource Management. Jakarta: Earth Literacy
Sigit, Achmad. 2009. Effect Direction Function Head of Space and Chairman of the
Executive Nurse Job Satisfaction In Blambangan Hospital Banyuwangi. Thesis Faculty
of Nursing. University of Indonesia. Jakarta
Simamora, RH .2012. Textbook of Nursing Management. Jakarta: EGC
Siswanto. 2016. Energy Management Indonesia. Jakarta: PT. earth Literacy
Suarli, S and Bahtiar, Y.2013. Nursing Management. Jakarta: Erland
Sudarmanto. 2009. Performance and Human Resources Development (Theory, Dimensional
Measurement and Implementation in Organizations). Yogyakarta: Library Learning
Sugiono. 2012. Quantitative and Qualitative Research Methods. Bandung: Alfabeta
Sumirat, T. 2014. Relationships Work Motivation Nurse with Nursing Care Quality
Documentation of patient wards in hospitals Panembahan Disease Senopati Bantul,
Yogyakarta. Aisyiyah STIKES manuscript publication. Yogyakarta
Setiadi. (2013). Writing Concepts and Practice of Nursing Research (2nd ed.). Yogyakarta:
Graha Science.
Swansburg. RC. 2000 Nursing Leadership and Management, for clinical nurses. Jakarta. EGC
Triwibowo, C. 2013. Management of Nursing Services at the Hospital. Jakarta: Trans Media
Info
Warsito, BE, and Mawarni, A. 2007. Influence Perceptions About Nurse Executive
Managerial Function Head of Implementation Activities in Space Management Nursing
Inpatient RSJD Dr. Amino Gundohutomo Semarang, 1 (1)
Wirawan, 2009. Performance Evaluation of Human Resource Management. Jakarta: Four
Salemba
DOI: http://dx.doi.org/10.52155/ijpsat.v14.1.819
Refbacks
- There are currently no refbacks.
Copyright (c) 2019 Nopan Saputra, Hema Malini, Mira Susanti
![Creative Commons License](http://i.creativecommons.org/l/by/4.0/88x31.png)
This work is licensed under a Creative Commons Attribution 4.0 International License.