10 Legal aspects of care documentation (5)Legal aspects of care documents Legal aspects of care documentation (5) The process of managing care problems is described in an unbroken circle, the tdd: Data collection Data processing Output Feedback. To support the implementation of all of the above activities, good record-keeping and documentation efforts are required. 1 LEGAL ASPECTS OF CARE DOCUMENTSCHORAL LEGAL ASPECTS OF CARE DOCUMENTATION LEGAL ASPECTS OF CARE DOCUMENTS By: RISA NURHAYATI 7 Legal aspects of care documentation (2)Legal aspects of care documents Legal aspects of care documentation (2) In the performance of their duties, nurses need the client`s health data as a basis for determining the model of care, It is therefore very necessary to document care It must be of It can be assumed that the success of the goals of care depends largely on the success of the documentation mechanism. 6 Legal aspects of care documentation (1)Legal aspects of care documents Legal aspects of care documentation (1) In the Law of the Republic of Indonesia No. 23 of 1992 on health states the following: That the cure of diseases and the restoration of health are carried out through treatment and / or treatment On this basis, it can be concluded that care services clearly play an important role in the cure of diseases and the restoration of health. 9 Legal aspects of care documentation (4) Legal aspects of care documents Legal aspects of care documentation (4) Off The above government decree stipulates that the nurse must be able to make nursing decisions in the exercise of her duties and powers, the process is carried out on the basis of nursing science, the capacity to govern issues and the authority associated with the nursing profession. 2 Legal aspects of care documentationLegal aspects of care documents Document definitions: According to (Tungpalan, 1983); A document is a document or record that can be proven valid or used as legal evidence. Documentation process: A set of “action processes” resulting from the recording or recording of events of a service delivery object or activity or services considered valuable and important 8 Legal aspects of care documentation (3)Legal aspects of care documents Legal aspects of care documentation (3) Government Decree of the Republic of Indonesia, OoO 32 of 1996, concerning health workers, chapter I, article 11, which provides as follows: Health personnel are any person who is dedicated to the field of health and who possesses the knowledge and/or skills necessary for training in the field of health for certain types of authorities to carry out health efforts. 14 Legal aspects of nursing documentation (8)Legal aspects of care documents Legal aspects of nursing documentation (8) It is therefore clear that laws, official regulations and health regulations that provide for the obligation for health care workers to document their work in the medical record also apply to the nursing profession. 13 Legal aspects of nursing documentation (7)It is clearly stated that medical records contain a file containing both medical records (doctors) and paramedical records (nurses), as well as the records of other health professionals who cooperate in carrying out those health care efforts. On the basis of the above, and taking into account the responsibility of the duties of the profession with all the risks of its liability before the law, nursing documentation is indeed recognized for its existence and validity and has a position equivalent to other medical documents.
Legal aspects of care documents Art. 16 Basic documentation on the substance of care (2)Legal aspects of care documents Basic substance of nursing documentation (2) Two important documents Things to consider when creating care documents Always perform a real, factual and realistic registration process, The results of the files must be clear, systematic and directed. The accuracy and completeness of care documents, in addition to improving the quality of care, can also prevent misreading, errors in judgment and determination, and management errors that can endanger the client`s life. 4 Other definitions of care documents: Legal aspects of care documents Other definitions of care documents: Is comprehensive information that includes the client`s health status and the client`s needs. Includes nursing activities as well as the client`s response to the care they receive. 15 Basic substance of nursing documentation (1) Main objectives of nursing documentation Communication interests, namely: (1). As a means of coordinating care, (2). To avoid repetitive information, (3). Ways to minimize errors and improve the application of care, (4) Regulate the use of time to be more efficient.
Facilitate the accountability and accountability mechanism because: (1) Responsible for both the quality of care and the accuracy of implementation (2). As a means of legal protection for nurses when litigation takes place before the courts. Legal aspects of maintenance documents Art. 18 Requirements for the completeness of maintenance documentsLegal aspects of maintenance documents Requirements for the completeness of the maintenance document Take notes immediately after maintenance is completed. Start saving documentation with a time (date, month, year) and end it with a signature and a real name. Write down real and relevant facts. Notes should be clear, written in ink in plain language, and easy to read. Review the notes and correct any errors as soon as possible. Make a copy for yourself, as the nurse must be responsible for the information she writes. SPAP, AUDIT REPORT, PROFESSIONAL ETHICS AND LEGAL OBLIGATIONS 19 Legal aspects of interview documentsDo not remove or close the wrong font with an Ex or other type liquid, but make a horizontal line in the middle of the wrong font, write the word “false”, then paraphrase it, then write the correct note next to or above, to make it appear as a substitute for the wrong font.
Do not write comments critical of clients or other health professionals. Write only an objective description of the client`s behaviour and the actions taken by health care workers. Avoid general, diplomatic, and directionless writing, but write them thoroughly, concisely, concisely, and objectively. If there is a questionable order or instruction, enter a note or letter: clarification needed Do not leave the nurse`s final note blank, close the sentence with a clear punctuation mark or a period indicating that the sentence is finished. 17 Legal Standards of Care DocumentsDocuments relating to the legal aspects of careDocuments relating to legal standards of care Documentation of care must respect and understand the legal basis Nursing records provide appropriate information about the patient`s condition, including a specific process of care, regular assessments, and reflect vigilance against worsening client circumstances. Keep a brief record of the nurse`s communication with the doctor and the treatment procedures performed Pay close attention to the facts regarding the application of the nursing process. Always pay attention to the patient`s treatment situation and note in detail the patient`s health problems, especially in patients who have complex problems or serious diseases. 3 Legal aspects of care documentsEvidence of recording or reporting of activities related to activities to implement the client care process is useful for the benefit of clients, nurses and work partners? Legal aspects of care documents The problem of the formation of legal products in the environment of the Universitas Airlangga Radian Salman, S.H., LL.M.