TUGAS BAHASA INGGRIS
OLEH :
KELOMPOK 3
TINGKAT 2 REGULER A
Farida Boimau PO. 530320119116
Ferensina Selan PO. 530320119117
Fransiska Romana Ndamanggilik PO. 530320119119
POLITEKNIK KESEHATAN KEMENKES KUPANG
PRODI D-III KEPERAWATAN KUPANG
TAHUN 2020
WARMER
1. What are they doing ?
2. Who is in the bed ?
3. Who is standing? What it she doing ?
4. What is in the screen?
Answer
1. They are currently consulting about the patient’s condition
2. Patient
3. Nurse, she is talking to the patient in front of him
4. The results of the examination
VOCABULARY SECTION
1. Nursing documentation : dokumentasi keperawatan
2. Quality care : perawatan berkualitas
3. Patient records : catatan pasien
4. Hands on : tangan
5. Legal document : dokumen hukum
6. Coworkers : rekan kerja
7. Chart : grafik
8. Team effort : upaya tim
9. Financial : keuangan
10. Reimbursement : penggantian
11. Third party payer : pembayar pihak keriga
12. Scrutinized : diteliti
13. Potential litigation : potensi litigasi
14. Lawsuit : gugutan
15. Medical malpractice : malpraktek medis
16. Plaintiff attorney : pengacara penggugat
17. Board of nursing : dewan keperawatan
18. Abbreviation : singkatan
19. Subpoenead for deposition : surat panggilan pengadilan untuk deposisi
20. Witness at trial : bersaksi di pengadilan
21. Laws and rules : hukum dan aturan
22. Falsified documentation : dokumentasi yang dipalsukan
23. Sobering experience : pengalaman yang serius
24. Medocation errors : kesalahan meditasi
25. Legibly : secara jelas
26. Shift : shift
READING SECTION!
Exercise 1: Work in pairs. Read quickly
1. What is the first step in recording good documentation?
2. What does ‘write legibly’ mean ?
Answer
1. Be accurate, chart objective,and dont chart that the patient fell if you find a patient on
the floor, chart as soon as possible after care is given, write legibly, use only approved
abbreviations.
2. Tulislah dengan jelas
Exercise 2: Work in small groups. Read the following passage.
1. What do you know about documentation mentioned in the passage ?
2. What new knowledge that you learnt from the passage ?
Answer
1. Nursing documentation is part of the implementation of nursing care that has legal
value. Without nursing documentation, all nursing implementations that have been
carried out by each nurse will not have value and meaning in responsibility and
accountability. Nursing documentation is 'authentic evidence' written in The format is
available and is affixed with the initials and signature / initials of the nurse's name and
is also integrated into the patient's medical record. In the implementation of nursing
care for patients, each step of the nursing process starts from assessment, determining
nursing diagnoses, intervention, implementation and evaluation. nursing must be
included in the nursing documentation.
2. Nurses create and edit patient records many times during any work day. We may even
complain that we spend more time charting than we do with our patients. Although
that may be true, we should remember that patient care isn’t just “hands Gon.”
Documentation in nursing is also an integral part of providing quality and safe care to
our patients.
WRITING
Exercise 1: Write a short informal nursing report toyour colleagues.
Write a paragraph explaining what do you usually do at the hospital for nursing
documentation.
Answer
NURSING DOCUMENTATION One of the duties of a nurse is to do nursing
documentation. Nursing documentation is a record containing patient complaints and actions
that must be taken by the nurse so that the patient returns to health. Nursing documentation
consists of assessment, nursing diagnosis, planning, implementation and evaluation.
The assessment is carried out when the patient first enters the hospital, for example
assessing the patient's complaints so that they come to the hospital. follow-up studies to
complement the initial assessment such as conducting laboratory examinations. then
reassessment to determine the patient's progress, for example, does the patient still feel dizzy?
or can the patient perform personal hygiene independently?
Nursing diagnosis is the determination of clinical nurse decisions for complaints and
pain that the patient feels during the assessment. For example, when the patient coughs with
phlegm and has difficulty breathing, a diagnosis can be made of "ineffective airway clearance
associated with retained secret".
Planning is an action that will be taken by the nurse so that the patient returns to
health. For example, a patient who experiences shortness of breath due to a cough with
phlegm, the nurse should plan for giving education on deep breathing and coughing
effectively.
Implementation is the provision of actions that have been planned, such as training the
patient to cough effectively.
Evaluation is to assess the patient's progress based on the implementation done. such
as after coughing effectively 2 times a day the patient shows a regular breathing pattern.
therefore, a nurse must carry out nursing documentation tasks according to the flow so that
the patient achieves health. a nurse must always be responsible for every action taken.
