TUGAS BAHASA INGGRIS II

NURSING DOCUMENTATION

OLEH
KELOMPOK lll (TK. II REG A)

1 . EUGENIUS ARDIAN SATI

2. ENJEL ADRIANUS MUSA TANOEN

POLITEKNIK KESEHATAN KEMENKES KUPANG

PRODI D III KEPERAWATAN
TAHUN 2020
A. Warmer
1. What are they doing ?
 A nurse is explaining to the patient about the action to be taken and asking
for the patient's consent so that the nurse can do the documentation
correctly
2. Who is in the bed ?
 Patient
3. Who is standing ? what it she doing ?
 A nurse. A nurse is explaining the image on the screen to the patient so
that the patient can know the condition he is experiencing right now
4. What is in the screen ?
 On the screen, results of examination of the patient's current condition

B. Vocabulary Section
1. Dokumentasi keperawatan
2. Perawatan yang bermutu
3. Catatan pasien
4. Menangani
5. Dokumen legal
6. Rekan kerja
7. Bagan
8. Upaya tim
9. Keuangan
10. Penggantian
11. Pembayar pihak ketiga
12. Diperiksa
13. Gugatan potensial
14. Gugatan
15. Malpraktik medis
16. Pengacara penggugat
17. Bidang keperawatan
 18. Singkatan
19. Dipanggil untuk bersaksi
20. Saksi di pengadilan
21. Hukum dan aturan
22. Memalsukan dokumentasi
23. Pengalaman yang menenangkan
24. Kesalahan pengobatan
25. Terbaca dengan jelas
26. Pergantian

C. Reading Section
Exersice 1. Work in Pairs. Read quickly.
1. What is the first step in recording good documentation ?
The first step that must be taken in recording good documentation is Be accurate.
For example, do not use vague terms such as “good urine output.” How many
cc’s are “good?” Chart the specific amount and what the urine looks like.
2. What does ‘write legibly’ mean?
Write legibly namely where in writing / recording documentation Nursing should
be easy to read and understand by other nurses or other professions participate in
the documentation process.

Exersice 2. Work in small groups. Read the following passage.

1. What do you know about documentation mentioned in the passage.
According to our group nursing documentation is a record that contains all the
data needed to determine nursing diagnoses, nursing planning, nursing actions,
and nursing assessments that are systematically compiled, valid, and can be
morally and legally accountable and also nursing domination must also have a
part integral.
2. What new knowledge that you learnt from the passage.
The knowledge that our group can take is that every time we study data or status,
we must be careful because it can affect the determination of treatment. if
something goes wrong it can lead to bad things.
D. Writing
Nursing documentation that is usually carried out by nurses in the hospital, namely nurses
performing diagnostic examinations, including X-rays, MRI, laboratory, ultrasound, pap
smears, endoscopic CT Scan, and others. Then perform a medical resume for a summary
of the services provided during treatment until the patient is discharged from the hospital
either alive or dead.