Analysis the Completeness of Integrated Patient Development Records in Diabetes Mellitus Patients

Authors

  • Citra Suraya Department of Nursing, Lincoln University, Malaysia
  • Tukimin bin Sansuwito Faculty of Nursing, Lincoln University, Malaysia
  • Aris Citra Wisuda Program Studi Keperawatan, Sekolah Tinggi Ilmu Kesehatan Bina Husada Palembang, Indonesia
  • Rusmarita Program Studi Ilmu Keperawatan, Sekolah Tinggi Ilmu Kesehatan Bina Husada Palembang, Indonesia

DOI:

https://doi.org/10.56988/chiprof.v2i3.36

Keywords:

Effects, Diabetic foot exercices, Diabetic Mellitus

Abstract

The Integrated Patient Development Record documents interprofessional collaboration in patient care for health services, especially for patients with chronic problems, including diabetes mellitus. This study aims to determine the completeness of integrated patient progress records in diabetes mellitus patients. This type of research uses a qualitative descriptive method with a sample of 45 people and interviews with five respondents. Based on the research results, 11 forms (24.5%) had data filled in, and 34 forms (75.5%) had incomplete data. The problem factor in filling out integrated patient progress notes lies in verifying the responsible doctor and the results of the service provider's professional instructions. This is due to the large number of patients and limited time. The author provides suggestions for filling out integrated patient progress notes to support accreditation document service standards: a) increase the professional accuracy of service providers in filling out incomplete integrated patient progress notes. b) there needs to be socialization regarding standard operational procedures for integrated patient recording to minimize incomplete forms.

References

P. K. Whelton et al., "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults," Hypertension, vol. 71, no. 6, pp. E13–E115, 2018, doi: 10.1161/HYP.0000000000000065.

Z. Azahra, "Nursing care of patients with nutritional disorders in cases of type diabetes mellitus 2," vol. 18, pp. 1–23, 2022.

R. Ramdani, "Nursing Care for blood glucose instability in patients with diabetes mellitus," Karya Tulis Ilm., vol. 2, no. 4, pp. 1–16, 2018.

Annisa, "Nursing Care of Patients with Type II Diabetes Mellitus in the Inpatient Room of Bagindo Aziz Chan Rs Tk. IIIDr. Reksodiwiryo Padang,” Pustaka.Poltekkes-Pdg. Ac.Id, 2021.

N. Natasya and A. Alini, “Nursing Care With Diabetes Mellitus Type II,” J. Kesehat. Tambusai, vol. 1, no. 3, pp. 24–32, 2021, doi: 10.31004/jkt.v1i3.1234.

M. Nurfitri, "Diabetes Mellitus Nursing Care and application of progressive muscle application," Braz Dent J., vol. 33, no. 1, pp. 1–12, 2022.

J. V. Hickey and E. R. Giardino, "The Role of the Nurse in Quality Improvement and Patient Safety," J. Neurol. Neurosurg. Nurs., vol. 8, no. 1, pp. 30–36, 2019, doi: 10.15225/pnn.2019.8.1.5.

Herdman and T. Heather, NANDA International Nursing Diagnoses Definitions & Classification, Twelfth. New York, USA: Thieme Medical Publishers, Inc., 2021. doi: 10.1055/b000000515.

A. Iula et al., "Quality of care: Ecological study for the evaluation of completeness and accuracy in nursing assessment," Int. J. Environ. Res. Public Health, vol. 17, no. 9, pp. 1–9, 2020, doi: 10.3390/ijerph17093259.

Ministry Of Health Republic Indonesia, "Main Results of Basic Health Research," Kementrian Kesehatan RI, 2018.

A. A. Hidayat, Nursing Process NANDA, NIC, NOC, and SDKI Approaches, Pertama. Surabaya, Indonesia, 2021.

M. Fukada, "Nursing competency: Definition, structure and development," Yonaga Acta Medica, vol. 61, pp. 1–7, 2018, doi: 10.33160/yam.2018.03.001.

H. Kamil, R. Rachmah, E. Wardani, and C. Björvell, "How to optimize integrated patient progress notes: A multidisciplinary focus group study in Indonesia," J. Multidiscip. Healthc., vol. 13, pp. 1–8, 2020, doi: 10.2147/JMDH.S229907.

C. A. I, E. A. Zanatta, and S. C. Abido, "Evaluation of nursing records through Quality Diagnosis, Interventions and Outcomes inpatient progress notes," pp. 1–19, 2022.

A. Abd El Rahman, M. Ibrahim, and G. Diab, "Quality of Nursing Documentation; progress notes in damage evaluation and its impact on Continuity of patient care," Menoufia Nurs. J., vol. 6, no. 2, pp. 1–18, 2021, doi: 10.21608/menj.2021.206094.

J. Alasad, "Patient satisfaction with nursing care: Measuring outcomes in an international setting," J. Nurs. Adm., vol. 45, no. 11, pp. 563–568, 2015, doi: 10.1097/NNA.0000000000000264.

K. Rørtveit, B. Saetre Hansen, I. Joa, K. Lode, and E. Severinsson, "Qualitative evaluation in nursing interventions—A literature review," Nurs. Open, vol. 7, no. 5, pp. 1285–1298, 2020, doi: 10.1002/nop2.519.

S. E. Cuda and M. Censani, "Assessment, Differential Diagnosis, and Initial Clinical Evaluation of The Pediatric Patient with Obesity: An Obesity Medical Association (OMA) Clinical Practice Statement 2022," Obes. Pillars, vol. 1, no. January, pp. 1–6, 2022, doi: 10.1016/j.obpill.2022.100010.

P. R. Kusumaningrum, E. Dharmana, and M. Sulisno, “The Implementation Of Integrated Patient Progress Notes In Interprofessional Collaborative Practice,” J. Ners dan Kebidanan Indones., vol. 6, no. 1, p. 32, 2019, doi: 10.21927/jnki.2018.6(1).32-41.

C. Urquhart, R. Currell, M. J. Grant, and N. R. Hardiker, "Nursing record systems: Effects on nursing practice and healthcare outcomes," Cochrane Database Syst. Rev., vol. 2018, no. 5, 2018, doi: 10.1002/14651858.CD002099.pub3.

M. Harding and D. Hagler, Conceptual Nursing Care Planning. Book Aid International, 2022.

C. María and C. Moreno-mulet, "Students and Teachers' Satisfaction and Perspectives on High-fidelity Simulation for Learning Fundamental Nursing Procedures : A Mixed-method Study," Nurse Educ. Today J., vol. 104, no. 2021, pp. 1–6, 2021, doi: 10.1016/j.nedt.2021.104981.

Mundakir, Y. Wulandari, and N. Mukarromah, “Pendekatan Model Asuhan Keperawatan Holistik Sebagai Upaya Peningkatan Kepuasan dan Keselamatan Pasien di Rumah Sakit,” J. Keperawatan Muhammadiyah, vol. 1, no. 2, pp. 7–16, 2016.

Downloads

Published

2023-08-31

How to Cite

Suraya, C., Sansuwito, T. bin, Wisuda, A. C., & Rusmarita. (2023). Analysis the Completeness of Integrated Patient Development Records in Diabetes Mellitus Patients. International Journal Scientific and Professional, 2(3), 182–186. https://doi.org/10.56988/chiprof.v2i3.36

Issue

Section

Articles