An Overview of Comprehensive Integration of Development Records and Nursing Documentation for Patients with Diabetes Mellitus
DOI:
https://doi.org/10.56988/chiprof.v3i1.63Keywords:
Diabates Mellitus, Integrated patient, development records and Documentation, Nursing Care, PatentsAbstract
Integrated patient development records form an integral part of nursing Integrated patient development records and Documentation, serving as a tangible representation of nurses' responsibility and accountability in executing their duties through interprofessional collaboration, while also offering authentic records of professional nursing care management. This study aims to elucidate the description of patient progress records and the completeness of nursing care Integrated patient development records and Documentation for Diabetes Mellitus patients in the Inpatient Ward of Siti Khadijah Islamic Hospital, Palembang. Employing a descriptive analytical approach with a cross-sectional design, the research involved purposive sampling, encompassing a total of 36 respondents. The findings revealed that among the respondents, 9 medical records (25%) were categorized as good, while 27 (75%) were classified as poor. Diagnosis results indicated that 28 medical records (77.8%) were deemed good, while 8 (22.2%) were rated as bad. Intervention records demonstrated that 3 respondents' medical records (8.3%) were assessed as good, whereas 33 respondents' records (91.7%) were categorized as poor. Implementation data showed that 26 respondents' medical records (72.2%) were in the good category, while 10 (27.8%) were in the bad category. Assessment outcomes showed that 5 respondents' medical records (13.9%) were considered good, while 31 (86.1%) were regarded as poor. Overall, Integrated patient development records and Documentation practices were observed among nurses in the inpatient ward at Siti Khadijah Islamic Hospital, Palembang; however, the implementation remains suboptimal. Statistical analysis of 36 medical records revealed that 24 (66.7%) were categorized as poor, whereas 12 (33.3%) were rated as good. Consequently, it is recommended to conduct standardized Integrated patient development records and Documentation training for both experienced and novice nurses, spanning across vocational and professional levels. Additionally, there is a necessity to establish and enhance nursing care instruments in alignment with standards, ensuring the optimal implementation of nursing process Integrated patient development records and Documentation
References
Harding M, Hagler D. Conceptual Nursing Care Planning. Newton L, editor. Book Aid International; 2022. 325 p.
Haugen N. Nursing Care Planning; Prioritization, DElegation, and Clinical Reasoning. Revised Reprint With 2021-2023 NANDA-I. 8th ed. Galura SJ, editor. New York; 2022. 750 p.
Herdman, Heather T. NANDA International Nursing Diagnoses Definitions & Classification. Twelfth. Kamitsuru, editor. New York, USA: Thieme Medical Publishers, Inc.; 2021. 61 p.
Ministry Of Health Republic Indonesia. Main Results of Basic Health Research. Vol. 53, Kementrian Kesehatan RI. 2018. p. 1689–99.
Hidayat AA. Nursing Process NANDA, NIC, NOC, and SDKI Approaches. Pertama. Aziz NA, editor. Surabaya, Indonesia; 2021. 105 p.
Hickey J V., Giardino ER. The Role of the Nurse in Quality Improvement and Patient Safety. J Neurol Neurosurg Nurs. 2019;8(1):30–6.
Al-Hussami M. Patients’ perception of the quality of nursing care and related hospital services. 2017;1(2):1–6.
Hamzah, Akbar H, Faisal, Rafsanjani TM. Basic Theory of Epidemiology of Non-Communicable Diseases. Sugiyatmi TA, editor. Aceh, Indonesia: Yayasan Penerbit Muhammad Zaini; 2021. 218 p.
Natasya N, Alini A. Nursing Care With Diabetes Mellitus Type II. J Kesehat Tambusai. 2021;1(3):24–32.
Annisa. Nursing Care of Patients with Type II Diabetes Mellitus in the Inpatient Room of Bagindo Aziz Chan Rs Tk. IIIDr. Reksodiwiryo Padang. PustakaPoltekkes-PdgAcId. 2021;
Mayang Sari N, Fitriyani N. Nursing Care of Type II Diabetes Mellitus Patients in Fulfilling Nutritional Needs. J Kesehat Univ Kusuma Husada Surakarta. 2022;56:1–9.
Creswell JW, Creswell JD. Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 5th ed. California: SAGE Publications, Inc; 2018.
Doengoes ME, Moorhouse MF. Nursing Care Plans; Guidelines For Individualizing Client Care Across The Life Span. 10th ed. Murr AC, editor. Philadelphia: F.A Davis Company; 2019. 819 p.
Nurfitri M. Diabetes Mellitus Nursing Care and application of progressive muscle application. Braz Dent J. 2022;33(1):1–12.
Novieastari E, Ibrahim K. Nursing Basics, Indonesian Editon. 2nd ed. Deswani, Ramdaniati S, editors. Jakarta, Indonesia: Elsevier Singapore Pte Ltd; 2020. 530 p.
Ramdani R. Nursing Care for blood glucose instability in patients with diabetes mellitus. Karya Tulis Ilm. 2018;2(4):1–16.
Thompson MR, Barcott DS. The Role of the Nurse Scientist as a Knowledge Broker. J Nurs Scholarsh. 2019;51(1):26–39.
Azahra Z. Nursing care of patients with nutritional disorders in cases of type diabetes mellitus 2. 2022;18:1–23.
Kozier & Erb’s. Kozier & Erb’s Fundamentals Of Nursing ; Concepts, Process and Practice. Tenth. Snyder SJ, Frandsen G, editors. Oakland, California: Julie Levin Alexander; 2016. 455 p.
Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: Effects on nursing practice and healthcare outcomes. Cochrane Database Syst Rev. 2018;2018(5).
Fukada M. Nursing competency: Definition, structure and development. Yonaga Acta Medica. 2018;61:1–7.
Fathya NA, Effendy C, Prabandari YS. Implementation of Interprofessional Collaborative Practice in Type B Teaching General Hospitals: a Mixed Methods Study. J Pendidik Kedokt Indones Indones J Med Educ. 2021;10(2):162.
Yusuf. Concepts and Methods of Nursing Clinic Guidance. Surabaya, Indonesia: Surabaya: Nursing Faculty, Airlangga University; 2019. 1–15 p.
Cuda SE, Censani M. Assessment, Differential Diagnosis, and Initial Clinical Evaluation of The Pediatric Patient with Obesity: An Obesity Medical Association (OMA) Clinical Practice Statement 2022. Obes Pillars. 2022;1(January):1–6.
I CA, Zanatta EA, Abido SC. Evaluation of nursing records through Quality Diagnosis, Interventions and Outcomes in patient progress notes. 2022;1–19.
NANDA. Nursing Diagnoses Definitions and Classification 2021-2023. 12th ed. New York: Theme Medical Publishers, Inc; 2021.
María C, Moreno-mulet C. Students and Teachers ’ Satisfaction and Perspectives on High-fidelity Simulation for Learning Fundamental Nursing Procedures : A Mixed-method Study. Nurse Educ Today J. 2021;104(2021):1–6.
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