Documentation of Nursing Care in Majauleng Health Centre Wajo District, Indonesia

International Journal of Research and Scientific Innovation (IJRSI) | Volume VIII, Issue III, March 2021 | ISSN 2321–2705

Documentation of Nursing Care in Majauleng Health Centre Wajo District, Indonesia

Isymarni Syarif¹, Besse Munawara², Abdul gafur^3
1,2Departement of Health Sciences, Islam University of Makassar
³Departement of Public Health, University of Pejuang Republic Indonesia

Abstract – Nursing documentation is a means of communication to other health teams regarding client status. Nursing documentation is very important to convey information about client status, help nurses communicate in the results of observations, decisions, actions, and results of the actions of nurses from clients. The aim of this research is to find out the description of the application of nursing care in nursing documentation at the Majauleng Community Health Center. The research method is consecutive sampling technique, with a sample of 33 respondents at Majauleng Public Health Center, Wajo Regency, with the type of research is quantitative, the research design used is descriptive. The results obtained were the application of nursing care with good categories as many as 22 respondents (66.7%), while the application of nursing care with poor categories was 11 respondents (33.3%). Conclusion: Documentation of nursing care with the 3S approach (SDKI, SLKI, SIKI) at the Majauleng Health Centre Wajo District Indonesia, has basically been done well by 66.7%, but there are still nurses who do not understand the documentation of nursing care. So it takes a case discussion reflection to all nurses to improve their skills and knowledge in documenting nursing care. This must be supported by the availability of facilities and infrastructure such as the format of nursing care and it is hoped that the support of the Health Centre leadership in monitoring nursing care documentation is expected.

Keywords – Nursing care, nursing documentation, Indonesian Nursing Diagnosis Standars (SDKI), Indonesian nursing output standards (SLKI), Indonesian nursing intervenstion standards (SIKI)

I. INTRODUCTION

Nursing services as an important part of health services need to be followed by increasing knowledge and skills, dignity and ethics of the nursing profession as mandated in article 41 of the Republic of Indonesia Law No. 38 of 2014 concerning nursing.[1]
Nursing is a form of professional service that is an integral part of health services based on nursing science and tips in the form of comprehensive/holistic biological, psychological, sociological and spiritual services aimed at individuals, families and communities who are either in a healthy or sick state that includes the entire process.[2] human life that refers to nursing as the main demand in three standard of nursing care services Indonesian Nursing Diagnosis Standard, Indonesian nursing output standards, Indonesian nursing intervention standards) which consists of assessment, diagnosis, intervention, implementation, evaluation.[3]

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