NURSING DOCUMENTATION

OLEH KELOMPOK 1 :
1. ADELVINA KARTINI KOME
2. ANDREAS MALO BULU
3. ANGELINA TAMO INA
4. ANJELA BUNGA TDEJU
5. ARYANTI PUTRI DANGGA MESA

TINGKAT I REGULER A
PROGRAM STUDI : D-III KEPERAWATAN
POLITEKNIK KESEHATAN KEMENKES KUPANG
2019/2020
UNIT 13:NURSING DOCUMENTATION

B.WARMER
Exercise 1.Work in pairs,look at the photo
1. The nurse is a documentation the patient
2. Patient
3. Nurse/documentation the patient
4. Patient rocords

D.VOCABULARY SECTION
Exercise 1.Translate the following phrases
1. Dokumentasi keperawatan
2. Keperawatan berkualitas
3. Catatan pasien
4. Tangan di atas
5. Dokumen legal
6. Rekan kerja
7. Grafik
8. Upaya tim
9. Penggantian
10. Keuangan
11. Pembayaran pihak ke tiga
12. Di teliti
13. Litigasi potensial
14. Gugatan
15. Malpraktek medis
16. Pengacara penggugat
17. Dewan keperawatan
18. Singkatan
19. Di panggil untuk desposisi
20. Bersaksi di pengadilan
21. Hukum dan aturan
22. Dokumentasi yang di palsukan
 23. Pengalaman yang serius
24. Kesalahan pengobatan
25. Secara jelas
26. Bergeser

E.READING SECTION
Exercise 1.Work in pairs.Read quickly
1. Nurses create and edit patient records many times during any work day.
2. Write legibly = tulisan dengan jelas

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

1. Documentation in nursing is also an integral part of providing quality and safe care to
our patients

2. We learn in nursing school that a patient record is a legal document. We also learn
that if it isn’t charted, it isn’t done. We should consider these fact in partical terms and
not just as something our instructors repeated numerous times

F.WRITING
Exercise 1.Write a short informal nursing report to your colleagues

In the hospital, it is usually done by nurses or other medical personnel who are
primarily caring for and treating patients, both outpatients and inpatients. But there are
also the duties of health workers that are carried out by them, namely writing nursing
documentation or what is often called nursing care. In nursing documentation, nurses
usually take notes record patient identity, patient examination, diagnosis, treatment,
action, and other services whether performed by doctors or other health professionals.
This documentation is usually used as a means of communication between doctors and
experts, written evidence, hospital files, protecting legal interests for patients, nurses and
other health workers and also to support and establish a patient’s diagnosis.