CHECKLIST

CRITICAL PATIENT DOCUMENTATION USING FLOW SHEETS

Name :
Student ID :

Score
No Assessment Components
1 2 3 4
Write down the patient's identity in the identity column
1 (register number, name, age, patient status and body
weight
2 Completeness and accuracy of writing nutritional therapy
Completeness of writing the doctor who treats and
3
diagnoses work (medical diagnosis)
Completeness and accuracy of writing the date of
4 documentation, day of care in the hospital and day of care
at the IPI / Intensive Care Installation
Completeness and accuracy of documenting vital signs
5
* The use of ink colors in documenting vital signs (blue:
temperature; red: pulse; green: tension)
Completeness and accuracy of documenting monitoring
6 results: CVP, ECG, level of consciousness, pupillary
reflexes & muscle strength)
Completeness and accuracy of documenting mechanical
7
ventilation settings
Completeness and accuracy of documenting the fluid therapy
8
given
9 Completeness and accuracy of documenting the output
Completeness and accuracy in documenting the medical
10
devices used
Completeness and accuracy of documenting
11
pharmacological therapy programs
Completeness and accuracy in documenting the results of
12
laboratory examinations and other supporting examinations
Completeness and accuracy in documenting the nursing
13
process (from assessment to evaluation)
Writing documentation is brief, detailed, easy to read
14
* use ink instead of pencil
 The ability to write the results of the assessment is accurate,
15
complete, objective and in order of time
Write down the full name and signature of the nurse
16
providing the care

Mark = (total score: 6,8) x 10

Surakarta, October 2019

Examiner

* Pass mark 70

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