Evaluation of the Implementation of the Documentation of Indonesian Nursing Diagnosis Standards in the Patient Room of RS Dr. R. Soetijono Blora

Abstract

Research background, Documenting standard nursing diagnoses in Indonesia is very important, however in practice there are still many obstacles that result in incomplete documentation. Nursing diagnosis as a component of Nursing Care Standards needs to be carried out properly as mandated in Law no. 38 of 2014 concerning Nursing in article 30 that in carrying out their duties as nursing care providers, nurses have the authority to determine nursing diagnoses.Research purposesto evaluate the implementation of the standard documentation of Indonesian nursing diagnoses in the Inpatient Hospital of dr. R. Soetijono Blora.Research methodsThe method used is the Observational Survey with a sample of 60 respondents. The instrument used was a questionnaire for the implementation of documenting standard nursing diagnoses in Indonesia.Research resultobtained the implementation of the Indonesian Nursing Diagnosis Standards documentation in the Inpatient Hospital of dr. R. Soetijono Blora was generally good 66.7%, 18.3% very good, and 15% less good. Documentation implementation that needs to be improved includes writing actual nursing diagnoses that must be supported by major and minor signs / symptoms, writing nursing diagnoses of risk and nursing diagnoses that have not been maximized, and writing nursing diagnosis code numbers.Research discussionrelating to the implementation of the Indonesian Nursing Diagnosis Standards documentation in dr. R. Soetijono Blora got poor results, one thing that needs to be anticipated is that nurses who do not have sufficient experience need to do training and habituation to carry out the process of enforcing nursing diagnoses systematically.Research conclusions In general, the implementation of the Indonesian Nursing Diagnosis Standards documentation has been carried out well, but it is necessary to carry out training and habituation to carry out the process of enforcing nursing diagnoses systematically