Gambaran Pengisian catatan Perkembangan Pasien Terintegrasi (CPPT)Deengan Diagnosa Nyeri Akut Oleh Peraat Di Instalasi Rawat Inap RSUD Dr Soewondo Kendal

Abstract

Integrated patient record contains additional information during problem solving management in the form of subjective data, objective data, analytical data and the usual new plan in short SOAP (Subjective, Objective, Analysis, Plan). The compliance of SOAP filling is very important because it contains various information and also used as the tool of justification, decision-making, and follow-up patient care. The purpose of this study is to find out the details about Integrated patient record with the diagnosis of acute pain by nurses at the Dr H Soewondo Kendal Hospital. This research is a quantitative research with descriptive survey method. The sampling technique used was total sampling and involved a sample of 134 CPPT documents. The results showed that filling in the development records of patients integrated with a diagnosis of categorized acute pain was quite good, namely 70 (52.2%,), categorized as good 34 (25.4%), and categorized as poor 30 (22.4%). There are 5 components in CPPT, namely the subjective component of filling in good categories, namely 109 (81.3%), in the well- categorized objective component of 109 (81.3%), in the good categorized analysis component, namely 105 (78.4%), and in categorized poor planning 74 (55.2%). So it can be concluded that filling CPPT with a diagnosis of pain is good enough. Based on the results of the study, it is highly recommended for the hospital to increase the standard for filling CPPT to make it better and hospitals Keywords: Integrated patient, record Subjectif, Objectif, Analysis, Planning. References: Integrated patient record 43 (2000-2017)