Optimization of Direction and Control Functions in Improving SOAP Writing in CPPT at X Hospital

Susana Helen Tanlain, Tuti Afriani, Dudi Mashudi

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.


Keywords


integrated patient development record; writing SOAP; improving; actuating; and controlling function

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Adamson, K., Maxwell, J., & Forbes, J. (2020). Journal of Interprofessional Education & Practice INTERPROFESSIONAL GUIDE to DOCUMENTATION in electonic health records. Journal of Interprofessional Education & Practice, 21(September), 100387. https://doi.org/10.1016/j.xjep.2020.100387

Aihatram, M., Nilima, N., Prathibha, J., Tiwary, B., & Singh, M. (2020). Documentation compliance of in-patient files : A cross sectional study from an east India state. Clinical Epidemiology and Global Health, 8(4), 994–997. https://doi.org/10.1016/j.cegh.2020.03.010

Andari, N. et al. (2021). Improving Methods Work Productivity of Medical Record Room Staff in Hospital Management Information a Regional General Hospital of Padang Sidempuan. Budapest International Research and Critics Institute-Journal (BIRCI-Journal). P. 1666-1676.

Akhu-Zaheya, L, Al-Maaitah, R, Bany Hani, S. Quality of nursing documentation: Paper-based health records versus electronic-based health records. J Clin Nurs. 2018; 27: e578– e589. https://doi.org/10.1111/jocn.14097

Alkouri, O. A., AlKhatib, A. J., & Kawafhah, M. (2016). Importance And Implementation Of Nursing Documentation: Review Study. European Scientific Journal, ESJ, 12(3), 101. https://doi.org/10.19044/esj.2016.v12n3p101

Araki, M. (2019). Patient Centered Care and Professional Nursing Practices. Journal of Biomedical Research and Clinical Investigation, 1(1). https://doi.org/10.31546/jbrci.1004

Dwi Nopriyanto, Rr. Tutik Sri Hariyati, Titin Ungsianik, Improving documentation of patient progress note through role empowerment of head nurse by Orlando theory approach, Enfermería Clínica, Volume 29, Supplement 2, 2019, Pages 182-188, ISSN 1130-8621, https://doi.org/10.1016/j.enfcli.2019.04.051. (https://www.sciencedirect.com/science/article/pii/S1130862119301512)

Fix, G. M., VanDeusen Lukas, C., Bolton, R. E., Hill, J. N., Mueller, N., LaVela, S. L., & Bokhour, B. G. (2018). Patient-centred care is a way of doing things: How healthcare employees conceptualize patient-centred care. Health expectations: an international journal of public participation in health care and health policy, 21(1), 300–307. https://doi.org/10.1111/hex.12615

Hussain, S. T., Lei, S., Akram, T., Haider, M. J., Hussain, S. H., & Ali, M. (2018). Kurt Lewin’s change model: A critical review of the role of leadership and employee involvement in organizational change. Journal of Innovation and Knowledge, 3(3), 123–127. https://doi.org/10.1016/j.jik.2016.07.002

Kamil, H., Rachmah, R., & Wardani, E. (2018). What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences, 9, 111–114. https://doi.org/10.1016/J.IJANS.2018.09.002

Komisi Akreditas Rumah Sakit. (2018). Instrumen-Survei-SNARS-ed-1-Tahun-2018-1.pdf (pp. 1–222).

Marquis, B. L., & Huston, C. J. (2012). Leadership and management tools for the new nurse: A case study approach. Wolters Kluwer Health/Lippincott Williams & Wilkins.

Marquis, B. L., & Huston, C. J. (2017). Leadership Roles and Management Fungtions in Nursing: Theory and Aplication (9th editio). Wolters Kluwer.

Pelletier, D., Duffield, C., Gietzelt, D., Larkin, P., & Franks, H. (2002). The complexities of documenting clinical information in long-term care settings in Australia. Journal of Gerontological Nursing, 28(5), 8–12. https://doi.org/10.3928/0098-9134-20020501-05

Permenkes RI No. 49. (2013). Komite Keperawatan Rumah Sakit.

Robbins, S. P., & Judge, T. A. (2017). Organizational Behavior, Seventeenth Edition, Global Edition. Pearson Education Limited, 747.

Stefancyk, Amanda MSN, MBA, RN, CNML; Hancock, Beverly DNP, RN-BC; Meadows, Mary T. MS, MBA, RN, CENP The Nurse Manager, Nursing Administration Quarterly: January/March 2013 - Volume 37 - Issue 1 - p 13-17 doi: 10.1097/NAQ.0b013e31827514f4

Sulistyadi, K., Ramli, S., & Abdullah, S. (2020). The Effect of Nursing Documentation and Communication Practices on Patient Safety Practices in the Pemalang Ashari Hospital. 3(1), 10–19.

UU RI No. 38. (2014). Keperawatan (Lembaran Negara Republik Indonesia No. 307).

Undang-Undang RI No. 44. (2009). Rumah Sakit (Lembaran Negara Republik Indonesia Nomor 153).

Wills, L. J. (1998). The perceptions of labor and delivery nurses concerning medical record documentation (Order No. 1393157). Available from ProQuest Dissertations & Theses Global. (304473228). https://www.proquest.com/dissertations-theses/perceptions-labor-delivery-nurses-concerning/docview/304473228/se-2?accountid=17242




DOI: https://doi.org/10.33258/birci.v4i4.2825

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