Authors :
Novtafia Endri; Hansen Nasif; Yelly Oktavia Sari
Volume/Issue :
Volume 8 - 2023, Issue 1 - January
Google Scholar :
https://bit.ly/3IIfn9N
Scribd :
https://bit.ly/3DCmBfI
DOI :
https://doi.org/10.5281/zenodo.7601377
Abstract :
Integrated Patient Progress Notes also known
as the Catatan Perkembangan Pasien Terintegrasi (CPPT)
is a documentation carried out by professional caregivers
about the development of a patient's condition in an
integrated form in the patient's medical record using the
SOAP (Subjective, Objective, Assessment, Plan) method.
Incomplete and unsuitable CPPT writing can affect the
continuity of care and the quality of patient care, which
will affect the patient's therapeutic outcomes. This study
aims to assess the completeness and suitability of writing
integrated patient progress notes by pharmacists at Ibnu
Sina Islamic Hospital Pekanbaru. This study is an analytic
descriptive study with prospective data collection using
total sampling from patient medical records. The inclusion
criteria in this study were CPPT written last by the
pharmacist. Medical records that meet the inclusion
criteria as research subjects are 32 CPPTs at Pharmacist 1
and 31 CPPTs at Pharmacist 2. From this study, the results
of the analysis of the completeness of CPPT writing at
Pharmacist 1 were that there were no CPPTs (0%) written
in full of the 32 CPPTs analyzed, and the results of the
analysis of the suitability of CPPT writing were 2 CPPTs
(6.25%) written in suitable with the 32 CPPTs analyzed.
The results of the analysis of the completeness of CPPT
writing on Pharmacist 2 are that there is no CPPT (0%)
written completely from the 31 CPPT analyzed, and the
results of the analysis of the suitability of CPPT writing are
as many as 3 CPPT (9.67%) written suitable from the 31
CPPT analyzed.
Keywords :
Integrated Patient Progress Notes; Pharmacist; Medical Records; Writing.
Integrated Patient Progress Notes also known
as the Catatan Perkembangan Pasien Terintegrasi (CPPT)
is a documentation carried out by professional caregivers
about the development of a patient's condition in an
integrated form in the patient's medical record using the
SOAP (Subjective, Objective, Assessment, Plan) method.
Incomplete and unsuitable CPPT writing can affect the
continuity of care and the quality of patient care, which
will affect the patient's therapeutic outcomes. This study
aims to assess the completeness and suitability of writing
integrated patient progress notes by pharmacists at Ibnu
Sina Islamic Hospital Pekanbaru. This study is an analytic
descriptive study with prospective data collection using
total sampling from patient medical records. The inclusion
criteria in this study were CPPT written last by the
pharmacist. Medical records that meet the inclusion
criteria as research subjects are 32 CPPTs at Pharmacist 1
and 31 CPPTs at Pharmacist 2. From this study, the results
of the analysis of the completeness of CPPT writing at
Pharmacist 1 were that there were no CPPTs (0%) written
in full of the 32 CPPTs analyzed, and the results of the
analysis of the suitability of CPPT writing were 2 CPPTs
(6.25%) written in suitable with the 32 CPPTs analyzed.
The results of the analysis of the completeness of CPPT
writing on Pharmacist 2 are that there is no CPPT (0%)
written completely from the 31 CPPT analyzed, and the
results of the analysis of the suitability of CPPT writing are
as many as 3 CPPT (9.67%) written suitable from the 31
CPPT analyzed.
Keywords :
Integrated Patient Progress Notes; Pharmacist; Medical Records; Writing.
