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iyer, P. 2001. Nursing malpractice. USA: ISBN.

Although many attorneys are familiar with narrative harting an! S"AP#I$% harting.

PI$ harting is less ommonly enountere!. &he initials in PI$ re'resent the

!oumentation of 'ro(lems, interventions, an! evaluation of nursing are. &he goalof PI$ harting as originally !esigne! in 1)*+, was to streamline !oumentation.

&his was aom'lishe! (y eliminating the tra!itional are 'lan an! inor'orating an

ongoing 'lan of are into the !aily !oumention.

1. ey elements&he PI$ system of harting onsist of -owsheets an! the 'rogress notes.

Progress notes use nursing !iagnosis as the 'ro(lem. &he 'ro(lem stetment

is la(ele! with P/ an! num(ere! for easy referene. or eam'le :ate &ime Progress notes # PI$ 3harting %

145 16.00 P71 ris8 for as'iration relate! to !erease! level of

onsiousness.

&he intervention that the nurse arrie! out to alleviate the nursing !iagnosis

are reor!e! net to an I/ an! are num(ere! to orres'on! to the 'ro(lem.

&he evaluation of the e9etivientions is reor!e! net to an $/ an!

num(ere!. or eam'le :ate &ime Progress notes # PI$ 3harting%145 16.00 P71 is8 for as'iration relate! to !erease! level of

onsiousnessI71 ;ea! of (e! elevate! to +< !egress for one hour after

eating.1+.00 $71 No evi!ene of as'iration.

In this system of !oumentation an evaluation of eah 'ro(lems are

a!!resse! eah !ay until the 'ro(lem resolve!.2. =e!i>ations of PI$ 3harting

&he PI$ metho! is often mo!i>e! in one or (oth of the following ways :A 'ro(lem list is !elove! to reor! the 'atient?s i!enti>te! 'ro(lemsAn a!!itional entry is ma!e in the 'ie note assessment >n!ngs are a!!e! to

ma8e the atually entry a'ie for eam'le5411 2200 a71 !isoriente! to time, 'lae an! 'erson.alling for her hus(an!

to hel' her get u' for (rea8fast171 reoriente! 'atient to use all (el assitae all (e 'lae! within reah2600 e71 'atient ontinue to (e !isoriuente!.has not use! all (ell.alls out

for her hus(an!A!vantage an! !isa!vantage of 'ie harting

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&he ma@or a!vantage 'ie harting is thaht its format enourages the use of

the nursing 'roess (y struting the 'rogress note to inlu!e nursing

!iagnose,interventions an! evaluation .the sytem also 'romotes the

systemati evalution of eah i!enti>te! 'ro(lem one every shift

&he 'rimary !isa!vantage of 'ie harting is that the 'lanning ste' of thenursing 'roess is not !oumente!. Pie harting s8i's from the 'ro(lem to

the intervensions that we arrie! out.althought e'eriene! nurses an ma8e

the lea' from nursing !iagnosis to intervension without !oumenting

'lanning. Novie nurses often have !iulty 'ermorming without a 'lan of

are.sta9 nurses usually !o not have time to review 'ages of 'rogress notes

to !etermine whih a''roahes have (een use! to resolve nursing !iagnoses.

&hey often rely on hangeofshift re'orts to !etermine the im'ortant nee!s

of the 'atient, as 8nowle!gea(le attorneys !isover when they Cuestionnurses in !e'ositions.

=es8i'un (anya8 'engaara yang a8ra( !engan narasi harting !an S"AP # I$ %

harting . PI$ harting 8urang umum !itemui . Inisial !i PI$ meru'a8an !o8umentasi

masalah , intervensi , !an evaluasi asuhan 8e'erawatan . &u@uan !ari PI$ harting

se(agai awalnya !iranang 'a!a tahun 1)*+ , a!alah untu8 meram'ing8an!o8umentasi. ;al ini !ila8u8an !engan menghilang8an renana 'erawatan

tra!isional !an mengga(ung8an renana 'erawatan (er8elan@utan 8e !alam

!o8umentasi seharihari.

1 . elemenelemen 8uni

Sistem PI$ harting ter!iri !ari -owsheets !an atatan 'er8em(angan . 3atatan

'er8em(angan mengguna8an !iagnosis 8e'erawatan se(agai masalah . =asalah

stetment !ila(eli !engan D P D !an !inomori untu8 referensi mu!ah . Se(agai

ontoh:&anggal Ea8tu ema@uan atatan # PI$ 3harting %

145 16.00 P 7 1 resi8o as'irasi (erhu(ungan !engan 'enurunan

ting8at 8esa!aran .

Intervensi yang !ila8u8an 'erawat untu8 mengurangi !iagnosis 8e'erawatan !iatat

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net 8e D I D !an nomor sesuai !engan masalah. $valuasi e9etivientions !iatat

se(elah D $ D !an (ernomor. Se(agai ontoh:

&anggal Ea8tu ema@uan atatan # PI$ 3harting %

145 16.00 P 7 1 isi8o as'irasi (erhu(ungan !engan 'enurunan

ting8at 8esa!aran

I 7 1 e'ala ti!ur !iang8at 8e +< !egress

selama satu @am setelah ma8an.

1+.00 $ 7 1 &i!a8 a!a (u8ti as'irasi .

alam sistem ini !o8umentasi8an setia' evaluasi masalah yang !itangani setia'

hari sam'ai masalah teratasi .

2 . =e!i>ations PI$ 3harting

=eto!e PI$ sering !imo!i>8asi !alam satu atau 8e!ua ara (eri8ut :

aftar masalah a!alah !elove! untu8 mere8am masalah i!enti>te! 'asien

$ntri tam(ahan !i(uat !alam 'ie atatan >n!ngs 'enilaian yang !itam(ah8an untu8

mem(uat a'ie se(enarnya masu8 misalnya

5411 22.00 P7 1 (ingung 8e wa8tu, tem'at !an 'erson.alling (agi

suaminya untu8 mem(antunya (angun untu8 sara'an

I 7 1 'asien !iorientasi8an untu8 mengguna8an

'anggilan (el assitae 'anggilan !item'at8an !alam @ang8auan

2600 e 7 1 'asien terus men@a!i !isoriuente!.has ti!a8 !iguna8an (ell.alls

'anggilan 8eluar untu8 suaminya

euntungan !an 8erugian !ari 'ie harting

euntungan utama 'ie harting yang thaht format men!orong 'enggunaan 'roses

8e'erawatan !engan nyusun atatan 8ema@uan untu8 memasu88an !iagnosa

8e'erawatan , intervensi !an evaluasi . Sytem @uga mem'romosi8an evalution

sistematis setia' masalah i!enti>te! se8ali setia' 'ergeseran

elemahan utama !ari harting 'ie (ahwa lang8ah 'erenanaan 'roses

8e'erawatan ti!a8 !i!o8umentasi8an . Pie harting melom'at !ari masalah 8e

intervensions (ahwa 8ita mem(awa 'erawat (er'engalaman out.althought !a'at

mem(uat lom'atan !ari !iagnosis 8e'erawatan untu8 intervensi tan'a

men!o8umentasi8an 'erenanaan . Perawat 'emula sering mengalami 8esulitan

'ermorming tan'a renana are.sta9 'erawat (iasanya ti!a8 memili8i wa8tu untu8

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menin@au halaman atatan 8ema@uan untu8 menentu8an 'en!e8atan telah

!iguna8an untu8 menyelesai8an !iagnosa 8e'erawatan . =ere8a sering

mengan!al8an la'oran 'eru(ahan 'eru(ahan untu8 menentu8an 8e(utuhan

'enting 'asien , se(agai 'engaara (er'engetahuan menemu8an 8eti8a mere8a

mem'ertanya8an 'erawat !i !e'osisi .