Implementation of Nursing Care Documentation Based on Indonesian Nursing Care Standards (SDKI, SLKI, and SIKI) in Hospitals

Abstract

Nursing documentation is a description of the actions given by nurses to patients in nursing care. This documentation consists of assessment, diagnosis, outcome, intervention, implementation, and evaluation. Nursing documentation should be evaluated in relation to its application in providing nursing care. There is still diversity in formulating nursing diagnoses due to the variety of nursing education, knowledge of nurses, and even differences in the reference standards used. Nurses at Kaliwates General Hospital Jember have different backgrounds from different educational institutions. Training is needed in providing nursing care, especially in the formulation of nursing diagnoses. The purpose of this service is to increase knowledge and skills as well as to apply the SDKI, SLKI, and SIKI books in the preparation of nursing documentation. This service method is by collecting information related to the knowledge and skills of nurses about the application of the SDKI, SLKI, and SIKI; training by providing materials; mentoring; and evaluating the application of this book in the nursing care documentation process.