PENDOKUMENTASIAN EARLY WARNING SCORE DI RUANG C DAN H BANGSAL KELAS III RS BETHESDA YOGYAKARTA

Background. Bethesda Hospital is currently working to implement EWS in all inpatient units to reduce the transfer of patients from nonintensive care to intensive care with the mortality rate of > 48 hours. Efforts to implement EWS are made by providing EWS training to inpatient nurses. EWS training are given to nurses in the inpatient units to ensure that the nurses are able to measure vital signs and record them in nursing documentation according to the established SOP. The implementation of the EWS needs to be evaluated as a management basis for improving service quality.
Purpose. This study aims to observe and gain understanding of EWS documentation regarding the examination of vital signs and the nurses responses to the results of the examinations in room C and H in Bethesda Hospital Yogyakarta.
Research Method. This study utilizes a descriptive design with a quantitative approach. The instrument used is a checklist that was made to observe EWS documents, which were randomly selected according to a predetermined sample.
Research Result. There were 26,1% instances of vital signs examinations regarding saturation that was not documented for low risk cases and 12.5% for moderate risk cases in room C. Meanwhile, in room H, there were 28.2% low risk cases and 16.7% moderate risk cases that were not documented. Follow up by nurses for low risk and moderate risk cases were not yet optimal. Nurses only report to the doctor in charge (DPJP/Dokter Penanggung Jawab Pelayanan) or activate the Blue Code when there is a change in the patient's physiological condition. However it was found in only 68% of moderate cases and 66.7% of monitoring.
Conclusion. Vital sign examinations has not been throroughly conducted and follow up for low risk and moderate risk cases were not yet optimal.