FOREWORD

Thanks to Almighty God who has bless to the writer and do not forget we thank
you for the assistance from those who have contributed by providing benefits
both mind and material. For finishing the English paper assignment entitled
“APPROACH TO THE NURSING DOCUMENTATION MODEL”. We hope
this assignment could increase our knowledge and experience for reader. Even
we believe that this assignment can apply to our life.
We believe there are still many shortcomings in the preparation of this paper
because of our limited knowledge and experience. For this reason, we sincerely
hope for constructive criticism and suggestions from the reader for the
perfection of this paper.
 CHAPTER I
PREFACE

1.1 Understanding

Nursing documentation is a record that can be proven or used as

evidence of all kinds of demands, which contain complete, real and recorded
data not only about the pain level of the patient, but also the type / type, quality
and quantity of health services to meet patient needs. (Fisbach 1991).

The purpose of the Nursing Documentation are to as Team member

communication tool, Biling finance, Education materials, Data sources in
compiling NCPs, Nursing audits, Legal documents, Statistical information,
Material research.

There are three nursing documentation model, are SOR (Source

Oriented Record), POR (Problem Oriented Record), 3) Progress Oriented
Record (POR).

SOR (Source Oriented record), This model places notes on the basis of the
discipline of people or sources that manage records. The client acceptance
department has its own form, doctors use sheets to record instructions, sheets of
disease history and disease progression, nurses use nursing records, as well as
other disciplines that have their own records.

POR (Problem Oriented Record), This model concentrates data about clients
documented and arranged according to client problems. This type of
documentation system integrates all data regarding problems collected by
doctors, nurses or other health professionals involved in providing services to
clients.

POR (progress-oriented-record) documentation model is a documentation

model that is oriented towards the development and progress of the client.

1.2 PROBLEM FORMULATION

1. What is the nursing documentation?

2. What is the nursing documentation model?

1.3 OBJECTIVES AND BENEFITS

1. Knowing the nursing documentation

2. Knowing the nursing documentation model

1.4 METHOD

The method used in this writing is literature and library media others.
 CHAPTER II
CONTENT

A. SOURCE ORIENTED RECORD (SOR)

1. Definition
Model documentation system is oriented on the source of the
information. This documentation allows each team member to make
their own health from observational results. The results of these studies
were collected into one. Each Member can carry out professional
activities independently without depending on other health team.
This model puts a record on the basis of the discipline of a
person or resource that manages the recording. Part of the reception of
the client has its own field sheets, doctors using the sheet instruction
sheets, to record the history of disease and disease progression, nurses
use the nursing notes, as well as other disciplines have a record each.
2. Source Oriented Records Component consists of several components,
namely:
a) Acceptance sheet contains background information.
b) Records of doctors.
c) Medical/illness history.
d) The nurse's notes.
e) Notes and special reports.
f) The form charts.
g) Form of the drug.
h) Form of records of nurses.
i) History of disease/treatment/examination.
j) Development of the patient.
k) The examination form lab, x-ray, etc.
l) The hospital sign-in Form.
m) Form for operations that are signed by the patient/family.
3. An example of the form of the SOR

Date Time Source Note developments

Date/month Time action N • Include:
(1) assessment,
/years
(2) identification of the problem,
(3) the need for a plan of action,
(4) the plan immediately,
(5) intervention,
(6) problem solving,
(7)
evaluation of the effectiveness actions,
and
(8) results.
• Signature of nurses.
D • Includes observations of the State of
the patient, the
evaluation of progress, the identification
 of new issues and
other settlement, plan of action and the
latest treatments.
• Signature of doctor.
P • Includes things to do physiotherapy,
problem patients,
planning, interventions, and outcomes.
• signature physiotherapist.
Signature and date.
Source:
N : nurses.
D : Doctor.
P : Physiotherapist.
N : Nutritionist.

B. POR ( problem oriented record )

POR is the development of the SOR documentation model. POR is an

effective tool for documenting a client-oriented health care system. This
documentation model leads to the ideas and thoughts of each team member, so
that team members can express their views in providing health services to
clients. This model facilitates teams in health planning actions and in
communication between team members.

This model concentrates client data, documented and then arranged

according to the problems experienced by the client. This model integrates all
data on client problems collected by doctors, nurses and other health workers
involved. The emphasis is not on who provides health services, but on the issue
of what nursing care is given to clients.

The POR documentation model consists of four components including:

1) Basic Data

Basic data is data obtained from the results of assessment when the
patient first entered the hospital. The basic data for nursing studies includes
medical history / previous care, physical examination of nursing, diet and
investigations, such as photographs, laboratory results. Based on the data
obtained from this basis it is used as the basis for determining client problems.

2) List of Problems

A list of problems containing data that has been identified from basic
data that is categorized as a problem. The problem data is arranged
chronologically according to the results of identification of priority problems.
Data is first compiled by health professionals who first meet clients or people
who are given responsibility. Categorizing data is grouped based on
physiological, psychological, socio-cultural, spiritual, growth, economic and
environmental problems. This list is on the front of the client's status and each
issue is given a date, number, formulated and the name of the person who
discovered the problem is stated and listed. Example:

Date List of problems Person who discovered

problem
1 mr. Andi experiences cva which Dr. doel
results in right hemiplegia and is
weak on the right side, the face is
not symmetrical
3). Preliminary List of Care Plans

The nursing care plan is organized based on the priority list and written in the
nursing care plan. When there is a collaboration action, the doctor will write
down the instructions on the medical record, then translate it by the nurse to
write it down on the treatment plan.

4) Progress Notes (Progress Notes)

Developmental notes contain about the progress experienced by the client on

every health problem experiences. Each health team involved in caring for the
client provides the report on the same progress sheet, arranged according to
their respective professionals. Here are some progress notes that can be used,
among others:

1) SOAP (Subjective data, data objectives, analysis / assessment and plan)

2) SOAPIER (SOAP plus Intervention, Evaluation and Revision)

3) PIE (Problem - Intervention - Evaluation)

Nurse records must be written by nurses every 24 hours, nursing

documentation contains information about:

1) Assessment

2) Independent nursing interventions

3) Collaborative nursing interventions / doctor's instructions

4) Evaluate the success of each nursing action

5) Actions taken by doctors but affect nursing actions

6) Visit of various health teams for example; visite doctor, social worker and
others.

 example of the POR format

Basic data List of problem Plan for action Note progress
Subjective data 1. 1.
2. 2.
Etc Etc
Objective data 1. 1.
2. 2.
Etc Etc

 Advantage
1) The focus of nursing care notes emphasizes client problems and problem
solving processes rather than documentation tasks

2) Recording of continuity from nursing care

3) Evaluation and resolution of problems are clearly recorded. Data is arranged

based on specific problems

4) List of problems is a "checklist" for nursing diagnoses and for client

problems. The list of problems helps remind nurses of attention

5) Data that needs to be intervened are described in the nursing action plan.

 Loss
1) The emphasis on only based on charity, illness and disability can result in a
negative treatment approach

2) Possible difficulties if a list of problems has not been taken action or new
problems arise

3) Can cause confusion if everything must be included in the list of problems

4) SOAPIER can cause unnecessary repetition, if there is often an evaluation

target and the client's development goals are very slow

5) Routine maintenance may be ignored in recording if the flow sheet for

recording is not available

6) P (in SOAP) duplication may occur with the nursing action plan.

C. Progress-oriented-record (POR) documentation model

The POR (progress-oriented-record) documentation model is a

documentation model that is oriented towards the development and progress of
the client.

Below are types of records that can be used in progress-oriented-record (POR)

nursing models, namely:

1. Assessment of one or more nursing staff about the condition of the client.
2. Independent nursing care.
3. Nursing care that is delegating.
4. Evaluate the success of each nursing care.
5. The actions taken by the doctor, which affect nursing care.
6. Visit of various members of the health team.

Groove sheets, including:

1. The results of observations made by nurses, measurements made repeatedly,

and which do not need to be written narratively.
2. Clinic records, fluid balance records in 24 hours, treatment notes and diaries
about nursing care.

The things that are needed in recording a client's return are:

1. Return notes and reference summaries

Writing of return documentation includes:
a. Health problems that still occur.
b. Last treatment.
c. Handling that still has to be continued.
d. Eating habits and rest.
e. The ability for self care.
f. Pattern or lifestyle.

Information for health professionals who will continue further client care
includes:

1. A description of the nursing intervention that will be given to the client.

2. Description of information that has been submitted to the client.
3. Description of the client's condition.
4. Explanation of the challenges of family involvement in nursing care.
5. A description of the resources needed at home.

Information for clients, including:

1. The use of clear and easy to understand language.

2. Explanation of certain procedures according to what the client needs.
3. Identify preventive actions that need to be followed or implemented by
clients when carrying out independent nursing care.
4. Examination of signs and symptoms of complications that need to be
reported by clients if experienced by clients later.
5. Giving a list of names and telephone numbers of health workers who
can be contacted by clients.
 CHAPTER III

Closing
A. Conclusion

Nursing documentation is a record that can be proved or made evidence from

all sorts of demands, which contains the complete data, real and recorded not
only about the level of pain of the patient, but also the kind/type, quality and
quantity health services in meeting the needs of the patient. In documenting
nursing consists of several types of models, namely:

1. SOR (Source Oriented records)

This Model puts a record on the basis of the discipline of a person or
resource that manages the recording. Part of the reception of the client has
its own field sheets, doctors using the sheet instruction sheets, to record the
history of disease and disease progression, nurses use the nursing notes, as
well as other disciplines have a record each.
2. POR (PROBLEM ORIENTED RECORDS)
This model concentrates data about clients documented and compiled
according to the client's problems. This type of documentation system
 integrates all the data about the problem is collected by doctors, nurses or
other health care personnel who are involved in administering the services
to the client.
3. POR (progress-oriented records)
This model is a model-oriented documentation development and
advancement of the client. this is a documentation model that is oriented
towards the development and progress of the client. That is where the progress of
the patient's condition are monitored and recorded thoroughly.

B. Suggestion

Nursing students must learn to understand and be able to distinguish the model
of nursing documentation and be able to apply it to the Nursing documentation.
Thus the nursing students will be able to become a better nurse again in the
future.