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All Journal Jurnal Keperawatan Indonesia Jurnal Keperawatan Jiwa (JKJ): Persatuan Perawat Nasional Indonesia JKG (Jurnal Keperawatan Global) Jurnal Keperawatan Silampari Jurnal Keperawatan Muhammadiyah Nursing Current : Jurnal Keperawatan Jurnal Keperawatan Abdurrab Jurnal Kepemimpinan dan Manajemen Keperawatan Jurnal Keperawatan Komprehensif (Comprehensive Nursing Journal) International Journal of Nursing and Health Services (IJNHS) Jurnal Keperawatan Respati Yogyakarta Poltekita : Jurnal Ilmu Kesehatan Health Information : Jurnal Penelitian Jurnal Bahana Kesehatan Masyarakat (Bahana of Journal Public Health) Jurnal Kesehatan Panrita Husada Jurnal Ners Jurnal Persatuan Perawat Nasional Indonesia (JPPNI) Journal of Telenursing (JOTING) Indonesian Journal of Global Health research Budapest International Research and Critics Institute-Journal (BIRCI-Journal): Humanities and Social Sciences Caring : Indonesian Journal of Nursing Science Jurnal Kesehatan Tambusai JOSING: Journal of Nursing and Health DUNIA KEPERAWATAN: JURNAL KEPERAWATAN DAN KESEHATAN Holistik Jurnal Kesehatan
Tuti Afriani
Department Basic Science & Fundamental Nursing, Faculty Of Nursing, Universitas Indonesia
Religion Arts Humanities Biochemistry, Genetics & Molecular Biology Dentistry Economics, Econometrics & Finance Education Environmental Science Health Professions Immunology & microbiology Languange, Linguistic, Communication & Media Medicine & Pharmacology Neuroscience Nursing Physics Public Health Social Sciences Veterinary

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Optimization of Direction and Control Functions in Improving SOAP Writing in CPPT at X Hospital Tanlain, Susana Helen; Afriani, Tuti; Mashudi, Dudi
Budapest International Research and Critics Institute-Journal (BIRCI-Journal) Vol 4, No 4 (2021): Budapest International Research and Critics Institute November
Publisher : Budapest International Research and Critics University

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33258/birci.v4i4.2825

Abstract

The provision of patient care in hospitals is carried out based on the concept of Patient-Centered Care (PCC). One of the dimensions of this PCC is the coordination and integration of care services. The integration of care services is carried out horizontally and vertically. The care provider professionals work as intra and interdisciplinary with interprofessional collaboration, assisted by an integrated patient development record written in SOAP form. As the most caregivers in hospitals, nurses must correctly record and document every patient's progress so that other professions can quickly use them. The phenomenon that occurs, doctors do not read or do not believe in the writings of nurses. Hospital X is a type a hospital, specifically in the intensive care unit; the average BOR in the last three months is 69.71%. Based on the observations, it was found that the writing of SOAP on integrated patient development records was not the same for every NurseNurse and not following the standards. So it is necessary to optimize the direction and control function of the Charge Nurse and the head of the room for writing SOAP on integrated patient development records to comply with Nursing Care Standards and SOPs for Hospital X. The method used is a pilot project, starting from data identification, problem analysis, problem priority setting, Plan Preparation of Action (POA), implementation, and evaluation. Data were collected by interview, observation, and survey methods using a google form containing questions about the knowledge and perceptions of nurses on writing SOAP on the integrated patient development record. With the direction and control/control, each level of the manager is expected to achieve organizational goals and improve the deviations found. For this reason, it is hoped that the hospital can accelerate the implementation of EMR synchronized with the nursing care standards that have been arranged and continue to carry out regular supervision in writing SOAP on the integrated patient development record.
Co-Authors Aat Yatnikasari Aat Yatnikasari Aat Yutnikasari ade herawati Ade Irma Dahlia Agustina, Frima Ulfa Ali Ahmad Keliobas Andi Nur Indah Sari Annisa Rahmi Galleryzki Arhamsyah Arhamsyah, Arhamsyah Azizah, Yuni Cori Tri Suryani Cori Tri Suryani Dadan Bardah Dadan Bardah Dahlia, Ade Irma Damayanti, Mira Dewi Gayatri Dina Warashati Dudi Mashudi Dudi Mashudi Dwi Suratmini Dyah Fitri Wulandari Dyah Fitri Wulandari Dyah Fitri Wulandari Eka Budiarto, Eka Elisabet Herlyani Bota Koten Enie Novieastari Erwin Erwin Erwin Eva Metalita Fahmi, Ismail Frima Ulfa Agustina Frima Ulfa Agustina Frima Ulfa Agustina Hanny Handiyani Harwina, Harwina Hening Pujasari Herawani, Herawani I Wayan Gede Saraswasta Istiqomah Istiqomah Kartika, Anika Khairul Nasri Khairul Nasri Krisna Yetti Krisna Yetti Krisna Yetti Kuntarti La Ode Abdul Rahman La Ode Rahman Laras Adythia Pratiwi Lilis Rayatin Lusia Dian Wahyu Winarti Lusianus Demon Kehi Manumba, Ruliyani Marbun, Yusniaty Masfuri - Mashudi, Dudi Mery Anglelia Sirait Metalita, Eva Mira Damayanti Mu'minah Mu'minah Nanang Miftakhul Wakhdi Nasri, Khairul Nurdiana Nurdiana Nurdiana Nurdiana Oktaviarini, Eva Pina Pudiyanti Putri Nilasari Rachmi, Shanti Farida Reidha Fitri Nurbaeti Resty, Dian Eka Retnoningtyas, Wahyu Kusumadi Rezky Mulyana Rita Herawati Rizka Fadhila Rizky Indriasari Rosari Tarigan Rr Tutik Sri Hariyati RR Tutik Sri Hariyati Rr Tutik Sri Hariyati Rr. Tutik Hariyati Rr. Tutik Sri Hariyati Rr. Tutik Sri Hariyati Rr. Tutik Sri Hariyati Rr. Tutik Sri Hariyati Rr.Tutik Sri Hariyati Sari, Fani Hestiana Sarvita Sarvita Dewi Sarvita Dewi Sarvita Dewi Setyowati Setyowati Setyowati Setyowati Siti Indriani Situmeang, Widiya Yulian Sudaryati Sudaryati Sudaryati Sudaryati Sudaryati Sudaryati Suminarti, Tini Sunarti, Arni Suryati Suryati Tanlain, Susana Helen Tini Suminarti Tomy Suganda Verdiansyah, Rio Vergeina Ayu Wahyuni, Tyas Wildani, Andi Amalia Wulandari, Dyah Fitri Yuliana Yuliana Yunita Yunita