Documentation Guidelines Research Articles

Didactic Instruction's Impact on Medicolegal Quality of Radiation Oncology Resident Physician Documentation.

Effective documentation serves as a cornerstone for communication and patient care, especially in radiation oncology (RO). Studies have shown room for improvement in documentation practices, and although documentation guidelines exist, it is uncertain if RO physicians are aware of or adhere to them. We aimed to assess RO resident physicians' medicolegal knowledge and the impact of an educational intervention on documentation practices. Grading rubrics for consultation and progress notes were created using guidelines, comprising of a fundamental score and total score. Residents from two institutions attended a didactic seminar on medicolegal documentation. Pre- and post-seminar, an electronic anonymous survey was used to assess resident knowledge and perspectives and random resident consultation and progress notes were scored. Mean documentation and survey item scores from pre- and post-seminar were compared. Fourteen resident physicians participated and completed surveys, and 48 consultation notes and 40 progress notes were analyzed. No participant had prior education specific to RO documentation, nor were any aware of available resources. Post-seminar, participants' medicolegal documentation knowledge significantly increased (86.61% vs. 95.54%, p = 0.001), as did the fundamental score (83.64% vs 89.29%, p = 0.041) and total scores of consultation notes (69.82% vs. 78.98%, p = 0.001) and total score of progress notes (55% vs. 75.19%, p < 0.001). Our seminar significantly enhanced residents' medicolegal knowledge and quality of documentation, and surveys revealed a lack of speciality specific documentation education. This combined with findings from other studies and participant opinions suggest that resident physicians would benefit from such training during residency.

ThP6.17 - ‘If it’s not documented, it didn’t happen’: an audit into surgical ward documentation and clinicians expectations in a district general hospital

Abstract Introduction &amp; Aims There are guidelines published by the Royal College of Surgeons (RCS) on adult surgical ward round documentation. Locally, documentation is done on pre populated sheets containing blood results, antibiotics and VTE prophylaxis. We aimed to assess documentation in our unit against the RCS guidelines. Methodology We audited documentation for surgical inpatients over 1 week, looking at daily ward rounds (DWR), and initial consultant post take ward round (PTWR). Through an online survey, we established the minimum standards of documentation expected by doctors of varying seniority on a ward round within our unit. Results 21 DWR and 21 PTWR entries were reviewed; 90% (n=19) contained the date and 95% (n=20) the name of the reviewing consultant. Time of review was documented in 29% (n=6) and 35% (n=7) respectively. 33% (n=4) DWR entries documented examination findings, compared to 8 40% (n=8) PTWR entries. 45% (n=10) PTWR contained the presenting complaint. 26 doctors completed the online survey; 100% thought date, time and examination findings were important. More senior doctors highlighted that drain status was a key part of ward round documentation. Conclusions Within our unit, there is poor adherence with the RCS ward round documentation guidelines. Juniors suggested this is because ward rounds are too fast paced, often on complex and comorbid patients. We plan to address our findings with an improved surgical admission proforma and an electronic handover to ensure all team members are up to date with patients’ admission details.

Analysis of the Youth Posyandu Program and Family Assistance Team in Efforts to Reduce Stunting in Tayu District, Pati Regency

Education is held to equip the community, especially the less fortunate, with the ability to maintain health that can be used to improve their quality of life. This case study research was conducted to analyze the Youth Posyandu and Family Assistance Team programs and to examine the impact of the implementation of the program. The research conducted in Tayu District, Pati Regency from September to November 2023 is a qualitative research. Data collection was carried out by the researcher himself as a research instrument using interview, observation, and documentation guidelines. Data analysis was carried out using qualitative data analysis techniques. To achieve data validity, triangulation and observation extension were carried out. The results of the study showed that there was a positive impact on the target group, although it was still at the individual level. Therefore, the Youth Posyandu and Family Assistance Team that will be developed need to emphasize their sustainability and accountability in community empowerment efforts. Keywords: program analysis, youth posyandu, family assistance team, non-formal education, impact

Implementation of the Cooperative Learning Model in Arts and Culture Subjects in Elementary Schools

This research aims to determine the planning, implementation and impact of the jigsaw type cooperative learning model on class V arts and culture subjects at SDN 1 Gumantar. The research subjects were the principal and teachers of arts and culture subjects. The research instruments are in the form of observation guidelines, interview guidelines and documentation guidelines that measure planning, implementation and impacts produced using the jigsaw type cooperative learning model in arts and culture subjects. Data collection techniques in this research used observation, interviews and documentation. Data analysis techniques are carried out using Data Reduction, Data Display (data presentation), Conclusion Drawing/Verification (drawing conclusions and verifying). There are various kinds of learning models that can be implemented in a learning activity. One of them is the jigsaw type cooperative learning model which is a learning model where students can learn to collaborate, work together and be responsible for understanding certain material and conveying it to their group friends. So that when implementing the jigsaw type cooperative learning model in arts and culture subjects, learning activities can indirectly foster the value of student cooperation. The objectives of this research are as follows: 1) to describe the planning of the jigsaw type cooperative learning model in arts and culture subjects, 2) to describe the jigsaw type cooperative learning model in arts and culture subjects, 3) to describe the impact of the jigsaw type cooperative learning model on The 11th unit of visual arts material culture lesson is making works of art from recycled household waste materials.

Objective acuity measures for infusion therapy staffing: A predictive model approach—Phase I.

e13553 Background: Acuity is a measure of the complexity of patient care and an estimate of nursing workload. The use of acuity tools is shown to improve care standards, nurse satisfaction and productivity. Existing acuity tools have barriers to adoption, including increased nursing workload, estimate variations among different nurses and clinical care settings, and poor understanding of validity of acuity measures. We aim to build a predictive model for prospectively determining acuity levels and staffing requirements in infusion therapy to address these gaps. This project will be implemented with a phased approach. Here we describe Phase I, to establish a standard measure and documentation process for acuity, then collect and analyze a large data set to quantify the relationship of acuity scores to selected patient characteristics. Methods: A US Oncology Network nursing committee developed evidence-based guidelines for acuity measurement and documentation in August 2023. Nine sites from four independent, community oncology practices were selected to perform acuity rating and documentation using the developed guidelines. Multiple training sessions on the guidelines were conducted with nurses from selected sites. Nurses documented acuity scores (level 1~6) and start time for patients’ infusion visits in the EHR 8/30/2023 – 11/30/2023. Acuity documentation rates were calculated and provided to each site weekly to gain feedback and engagement. Acuity scores were extracted from the electronic health record using natural language processing. Structured data on potential predictors including patient demographics, performance status, lab, and treatment-related information were also collected. Results: A total of 14,610 infusion room visits (5,139 distinct patients) with documented acuity scores were reported. The acuity documentation rate from each site was consistent by week and ranged 60 – 96%. Table reports prevalence of select features by acuity score. Conclusions: An operational workflow was successfully implemented to collect and analyze acuity scores and relevant features. Features of interest include chemotherapy Cycle 1 Day 1, five or more drugs and highly emetogenic treatment. In Phase II, the collected acuity scores and clinical features will be used to build a predictive model to objectively estimate acuity. Phase III will focus on the deployment of the predictive model to oncology practices. [Table: see text]

A comprehensive review of techniques for documenting artificial intelligence

PurposeCompanies are increasingly benefiting from artificial intelligence (AI) applications in various domains, but also facing its negative impacts. The challenge lies in the lack of clear governance mechanisms for AI. While documentation is a key governance tool, standard software engineering practices are inadequate for AI. Practitioners are unsure about how to document AI, raising questions about the effectiveness of current documentation guidelines. This review examines whether AI documentation guidelines meet regulatory and industry needs for AI applications and suggests directions for future research.Design/methodology/approachA structured literature review was conducted. In total, 38 papers from top journals and conferences in the fields of medicine and information systems as well as journals focused on fair, accountable and transparent AI were reviewed.FindingsThis literature review contributes to the literature by investigating the extent to which current documentation guidelines can meet the documentation requirements for AI applications from regulatory bodies and industry practitioners and by presenting avenues for future research. This paper finds contemporary documentation guidelines inadequate in meeting regulators’ and professionals’' expectations. This paper concludes with three recommended avenues for future research.Originality/valueThis paper benefits from the insights from comprehensive and up-to-date sources on the documentation of AI applications.

Project Based Learning Learning to Stimulate Symbolic Thinking Abilities in Children Aged 5-6 Years in Kindergarten Negeri Pembina 1 South Wangi-Wangi

This research aims to describe the implementation of Project- Based Learning to stimulate symbolic thinking of 5-6 years old children at Pembina 1 Kindergarten in South Wangi-Wangi. This research used a qualitative research approach with a descriptive type. This research was conducted at Pembina 1 Kindergarten in South Wangi-Wangi. The data source of this research was determined by purposive sampling techniques consisting of the principal, class B teacher, and group B students and supported by document data. The data were collected through interviews, observations, and documentation. The researcher was the main instrument in conducting the research with the help of observation, interviews, and documentation guidelines. The research results show the following findings: (1) project learning planning is carried out by preparing themes and learning topics, lessons plans, teaching modules, and projects reports. (2) The implementation of projects learning is carried out through projects activities to make fruit juice, cooking class, market day, lego construction, drawing and coloring, fruit media, blenders, or kitchen tools such as knives, spoons, and glasses, vegetables ingredients, pots and spoons, money, merchandise products, tables and chairs, legos, blocks, boards/bases, drawings paper/colouring books, pencils, colored pencils, and crayons. In the symbolic projects learning method, children determine learning objectives, project design, pre-project preparation, project implementation, reflection and evaluation, and classroom arrangement.

Application of family nursing documentation in Tarakan City, Indonesia

Documentation of nursing care is authentic proof of nursing service activities, serving as the basis for fulfilling nurses' responsibilities and accountabilities. Family nursing documentation holds distinct characteristics compared to other nursing practice settings. The Indonesian nursing professional organization has established three standards for nursing care: diagnosis, intervention, and outcome. This research aimed to understand how the implementation of family nursing care documentation is conducted by community nurses in Tarakan City. The research was a correlational study with a cross-sectional approach. The study population consisted of all the nurses working in Community Health Centers in Tarakan City, totaling 80 individuals. The sample was selected using total sampling. The research variables included demographic factors, nurses' knowledge about the documentation concept, and the application of family nursing documentation; these were measured using a modified researcher-made questionnaire and declared valid and reliable. The analysis of research data used descriptive analysis and the Spearman Rank correlation test. This research identified that the majority of community nurses in Tarakan City did not implement family nursing documentation, and the level of knowledge regarding nursing documentation concepts was low. The Spearman's rank correlation test yielded a p-value of 0.874, indicating no significant correlation between the level of knowledge and the implementation of family nursing documentation. The inhibiting factors for the implementation of family nursing care documentation primarily included a high workload, a limited number of health center nurses, motivation, and the lack of clear and uniform documentation guidelines.

Analisis Prosedur Sistem Informasi Akuntansi pada Siklus Penggajian Terhadap Karyawan: Studi Kasus BPDAS Jeneberang Saddang

A payroll accounting system is really needed in a company that can deal directly with employees. The payroll system functions in managing payment transactions for services carried out by employees who have a manager level position. Payroll-related activities (information regarding recruitment, dismissal, transfer, training, etc.) and collection of information regarding the use of employee time that occurs every day. However, the actual processing of payroll only occurs periodically because in most organizations employees are paid weekly, biweekly, or monthly rather than daily. Therefore, payroll is a continuous application that is processed in batch mode. The subject of this research is one of the administrative staff informants at the BPDAS Jeneberang Saddang office, while the results of this research are using documentation guidelines and interview guidelines taken using direct interview and documentation techniques. Data collection is carried out using a direct acquisition system from the parties concerned. Data analysis was carried out using qualitative descriptive analysis techniques. The research results show that the payroll system that occurs at the BPDAS Jeneberang Saddang office is in accordance with the Operational Procedure System (SOP) that has been established by the Ministry of Finance, namely the payroll system that is implemented at the BPDAS Jeneberang Saddang office is good in terms of providing documents relating to payroll system. The payroll system used by the BPDAS Jeneberang Saddang office is technology-based using the GPP (Central Civil Servant Salary) application system and other supporting documents such as changes to employee salary lists, making SPP (Payment Request Letters), SSP (Tax Payment Letters), SPM ( Payment Order), and finally SP2D (Funds Disbursement Order).

Documentation for Orthopaedic Surgery: An Audit to Ensure Compliance with the Most Recent Guidelines

Background: Consistent and thorough documentation in orthopaedic surgery is critical for ensuring quality patient care and protecting the legal interests of surgeons. Adherence to the Royal College of Surgeons (RCS) guidelines is fundamental to achieving this. However, studies have identified a persistent deficiency in compliance with these guidelines across various surgical specialities. Objective: The audit aimed to evaluate the existing compliance of orthopaedic surgical documentation with RCS guidelines at Dr. Ziauddin Hospital and to implement a tool to improve documentation practices. Methods: A closed-loop, two-cycle audit was conducted. The first cycle retrospectively analysed 200 surgical notes from January to July 2023, using a standardized operation sheet to assess compliance with RCS guidelines. Identified deficiencies were addressed by introducing an aide-memoir in all orthopaedic operating rooms. The second cycle prospectively analysed 100 surgical notes from August to October 2023 to evaluate the impact of the intervention. Results: The initial audit revealed a 0% compliance rate in documenting the date, time, and type of surgery (elective or emergency). Following interventions, the second cycle showed significant improvements, with compliance rates rising to 100% for date and time, and to 87% for identifying the surgery type. Additional documentation parameters such as the recording of the assistant's name and incision details also improved, though exact numerical increases were not specified. Conclusion: Introducing an aide-memoir significantly enhanced compliance with RCS surgical documentation guidelines. This simple, effective tool facilitated a remarkable improvement in the quality of operative notes, underscoring the need for regular audits and potential integration of electronic documentation systems.

Increasing Activity and Science Learning Outcomes Vibrations, Waves and Sound Matter Through STAD Model

Purpose of the study: In this research aims to determine increasing activity and science learning outcomes vibrations, waves and sound matter through student teams-achievment divisions (STAD) model.&#x0D; Methodology: This research is Classroom Action Research implemented in three cycles, each cycle consisting of four stages namely planning, observation, observation and reflection. The subject of this research are students of class VIII B of Pabelan 2 Public Middle School consisting of 32 students of 16 male students and 16 female students. Research instruments include observation guide sheet, questions and documentation guidelines.&#x0D; Main Findings: The results of the research show that the student teams achievement divisions (STAD) learning model can increase the activity and learning outcomes of Class VIII B students at State Middle Schools as evidenced by the increase in student learning completeness in Cycle I, 37.5% of students have completed learning, in Cycle II, 81% of students have completed learning and Cycle III 99% of students completed their studies.&#x0D; Novelty/Originality of this study: This research contributes to research with a new foundation in understanding scientific concepts through an innovative approach using the student teams-achievement divisions (STAD) model. The unique findings highlight STAD's significant contribution in stimulating student engagement and increasing achievement of learning outcomes, bringing new nuances to science education research.

ANALISIS PERHITUNGAN UNIT COST PELAYANAN SIRKUMSISI DENGAN PENDEKATAN ABC DI KLINIK SETIA BUDI JAMBI

Circumcision costing couter and conventional methods in Setia Budi Clinic Jambi using traditional accounting systems, so the services offered to be cheaper (under costing) or more expensive (over costing) of the costs that should be consumed on these services. It would be fatal to the hospital, especially in a highly competitive market conditions. Thus researchers need to review the unit cost in the circumcision services costing more accurate in the details of the cost and accuracy of charging better, then a decision will be taken by the management would be better and appropriate. Research performed using a qualitative descriptive design. Instruments used were documentation guidelines owned by hospital and stopwatch. Cost analysis method used is based on ABC (Activity Based Costing) system. The results of this study show units of cost to perform circumcision services at Setia Budi Clinic Jambi which is calculated using the Activity Based Costing (ABC) system is Rp 240.242,59 for the M conventional services and Rp 385.200,57 for M couter services. From the calculation of unit cost pelayananan circumcision in Clinical Setia Budi Jambi is calculated using the ABC method gives results smaller M convenstional service. While in service M couter, ABC calculation gives greater results.

Implementation of Women's Education in the Green Aksara Community in Dengok Village, Playen District, Gunung Kidul Regency for Sustainable Development

Abstract: This research aims to 1) describe the implementation of women's education for sustainable development by tutors and technical resource persons at the Green Aksara Association, 2) describe the supporting and inhibiting factors in the implementation of women's education for sustainable development. This research is descriptive research with a qualitative approach. The subjects of this research are institutional managers, technical resource persons, accompanying tutors and students who study. Data collection used participatory observation methods, in-depth interviews, and documentation. The researcher is the main research instrument with the help of observation guidelines, interview guidelines and documentation guidelines. The data analysis techniques used are data display, data reduction and conclusion drawing. Triangulation is carried out to explain the validity of the data using source triangulation. The results of the research show 1) the implementation of women's education for sustainable development in the green script community delivers environmentally friendly literacy and skills material, applied with participatory learning principles which appear in learning materials, learning preparation, preparation and learning stages, learning media and learning evaluation. 2) supporting factors for the implementation of women's education include the commitment of institutional management, support and participation from partners, application of participatory learning principles, and easy access to learning facilities. Meanwhile, the obstacles are increasing the time to repeat material for the elderly, learning time at the same time as agricultural activities, the educational skills possessed by the resource persons are still lacking.

Hegemony of Western Images in the Aesthetic Representation of Food Advertising in Indonesia

Hegemony of Western Images in the Aesthetic Representation of Food Advertising in Indonesia

Analysis of Interests Students in Learning Geography in Class XI IIS in MAN 1 Sintang

The objective of this research is to know how the interest of the students to study the subject of geography class XI IIS in MAN 1 Sintang, so that the teacher can find a solution to solve the problems felt by the students in their learning activities, so the students will gain success from their learning. The form of research used in this research is qualitative research with descriptive research methods. Data collection techniques in this study use observation, interview, and documentation methods. The data collection tools used are observation sheets, documentation and interview guidelines. Data analysis uses the Miles and Huberman model that consists of data reduction, data presentation, conclusion drawing. The results of the research showed that students of class XI IIS were interested in geography subjects. Students' interest in learning can be seen through 4 indicators, namely, the feeling of pleasure, the attention of the students, the involvement of students, and the willingness to learn the students. So students are said to be interested in geography subjects because they meet the four indicators of interest in learning.

Kerajinan Gerabah di Desa Melikan Kecamatan Wedi Klaten Jawa Tengah

Abstract This research aims to describe pottery crafts in Melikan village, Wedi sub-district, Klaten, Central Java, including the basic ideas for creating pottery, the materials and tools used, and the form of Wedi pottery crafts. This research uses a qualitative descriptive method, the instrument in this research is the researcher. To strengthen the research, researchers used observation, interview and documentation guidelines. The object of this research is the pottery craft industry in Wedi, Klaten, Central Java, and the research subjects are pottery craftsmen in Melikan village, Wedi subdistrict. The data analysis technique in this research is descriptive qualitative and uses stages, namely data collection, data reduction, data presentation, and drawing conclusions. Based on research results on pottery crafts in Wedi Klaten, Central Java, namely: The basic idea of creating pottery is motivated by market share or market orientation and also following the tastes of people who always demand maximum product production. The materials and tools used are Wedi clay as raw material for making pottery and munggur leaves as smoking material. The equipment used is mostly homemade, including a rotary table, gypsum mold, coconut leaf iron, cutting iron, scraper, tape measure, cutting wire, foam, boards and mosquito netting. The forms of pottery produced are eating and drinking utensils such as plates, bowls, teapots, piggy banks, then decorations such as flower vases, statues and jars.

Peer Tutor Method to Improve Problem Posing Ability

This study was conducted to determine the description of learning with the peer tutor method implemented through situation-based learning. The urgency of this study is to find out the problem posing ability of elementary school students as an intellectual skill that students must possess to support future competition. From the existing problems, students are accustomed to receiving knowledge without posing the problems they find. The peer tutor method through SBL facilitates students in problem-posing ability, problem-solving, and independent learning. The peer tutor method makes it easier for teachers to provide structured guidance to facilitate students through discussions. This study employed a descriptive qualitative method involving fourth-grade students, in which the data were obtained using observation, interview, and documentation guidelines. The obtained data were reduced to be able to conclude. This study found that learning through the peer tutor method involves active student roles, facilitates students to construct their knowledge in a guided manner, creates meaningfulness in students in posing problems, leads to follow-up questions, and responses to the problems posed.

Implementasi Penguatan Pendidikan Karakter pada Masa Pemulihan Pembelajaran Pasca Pandemi Covid-19 di SD Negeri 01 Tajur Kecamatan Kandangserang Kabupaten Pekalongan

This research aims to describe; (1) Implementation of strengthening character education during the learning recovery period after the Covid-19 pandemic at SD Negeri 01 Tajur, Kandangserang District, Pekalongan Regency; and (2) supporting and inhibiting factors in the implementation of strengthening character education at SD Negeri 01 Tajur Elementary School, Kandangserang District, Pekalongan Regency. This research is descriptive research with a qualitative approach. The research subjects were school principals, teachers and students. Data collection uses interview, observation, questionnaire and documentation methods. The research instrument uses interview guidelines, observation guidelines, questionnaires and documentation guidelines with researchers as human instruments. Data analysis uses interactive model analysis from Miles and Huberman which includes data collection, data reduction, data presentation, and drawing conclusions. The research results show that; (1) The implementation of strengthening character education during the learning recovery period after the Covid-19 pandemic at SD Negeri 01 Tajur, Kandangserang District, Pekalongan Regency is carried out through; (a) integration of character education values in the aspects of Discipline, Honesty, Respect, and Integrity Values in KBM; (b) extracurricular activities that reflect character education values; (c) Literacy/habituation created through school culture; and (2) supporting factors are communication, cooperation between school principals and teachers, socialization of the school board with the community and facilities.

Evaluating the Implementation of Formal Early Childhood Education in Pesantren in South Sulawesi

This article discusses the implementation of the Program Diniyah Formal (PDF) organized by four Islamic boarding schools in South Sulawesi, namely PDF Al-Junaidiyah in Bone Regency, PDF Asadiyah in Sengkang Regency, PDF Mangkoso in Barru Regency, and PDF Nahdatul Ulum in Maros Regency. This research is evaluative research using a discrepancy model. The purpose of this study is to examine whether there is a gap between the standards/criteria for implementing PDF and its actual implementation. The indicators used in this study are derived from the criteria for high school education set by the National Secondary School Accreditation Body (BAN-SM), which is divided into four aspects: graduate quality, learning process, teacher quality, and madrasah management. The instruments used include questionnaires, interview guidelines, and documentation guidelines. Based on the results, the evaluation of the quality of PDF graduates at Islamic boarding schools in South Sulawesi is classified as good. Meanwhile, the evaluation of the PDF learning process at Islamic boarding schools in South Sulawesi is classified as fair. Additionally, the evaluation of the quality of PDF teachers at Islamic boarding schools in South Sulawesi is classified as fair, while the evaluation of PDF madrasah management at these schools is also classified as fair.

Improving Procedure Text Writing Skills Through Make A Match Learning Model in Junior High School

This Classroom Action Research aims to improve students' ability in writing procedure texts through Make a Match learning model. The subjects in this study were 33 students of class VII A SMP Negeri 36 Semarang. Data were collected in one cycle through tests, classroom observation, and documentation. The tests were conducted in the form of pre-test, post-test of cycle I, and post-test of cycle II. The instruments used were test sheets, observation guidelines, and documentation guidelines. Data were analyzed using qualitative descriptive method. The results showed that students took an active role in their learning activities. The quality of their writing also improved. Their average score increased from 67 (Pre-test), 76 (Cycle I), and 82 (Cycle II). In conclusion, the use of Make a Match learning model is effective to improve students' ability in writing procedure text. The researcher hopes that the use of Make a Match learning model can be used by English teachers in teaching English, especially in teaching writing procedure text.