Aplikasi Standar Proses Keperawatan: Diagnosis, Outcome, dan Intervensi pada Asuhan Keperawatan
Abstract
This study aims to look at the quality of nursing care documentation at Myria Hospital Palembang. Analytic surveys are used to obtain an overview of nursing documentation as secondary data. Nursing care documents used were 105 documents by cluster sampling and measured using Q-DIO instruments, and analyzed descriptively. The results showed most of the medium quality in all dimensions, namely diagnosis as a process of 70 documents (67%), diagnosis as a product as many as 56 documents (53%), intervention as many as 66 documents (63%), and nursing outcomes as many as 67 documents (64%). The conclusions in this study indicate that 67% of records have moderate quality on the dimensions of diagnosis as a process, 53% of documents have a reasonable condition on the aspects of diagnosis as a product, 63% of records have moderate quality on the dimensions of intervention, and 64% of documents have average quality on the dimensions of output nursing. The results of the nursing process that have been obtained in this study illustrate the change or improvement in the improvement of symptoms that have a moderate quality to integrate with the nursing process.
Keywords: Diagnosis, Documentation, Intervention, Output
References
Daeli, N. E., Suwarno, M. L., & Budiharto. (2018). Perbedaan Kekuatan Otot Sebelum dan Sesudah Latihan Menggenggam pada Penderita Cerebrovascular Disease (CVD). Jurnal Kesehatan Saelmakers Perdana, 1(1), 38–43. https://doi.org/10.32524/jksp.v1i1.334
Herdman, T. H., & Kamitsuru, S. (2018). Nursing Diagnosis: Definitions and Classification (11th ed.). Thieme
Melin, J. C., Palmqvist, R., & Rönnberg, L. (2017). Clinical Intuition in the Nursing Process and Decision-Making – A Mixed Studies Review. Jounal of Clinical Nursing, 26(23–24), 3936–3949. https://doi.org/10.1111/jocn.13814
Muryani, P, E., & Setiawan, H. (2019). Kualitas Pendokumentasian Asuhan keperawatan di Ruangan Rawat Inap: Studi di RSUD Kalimantan Tengah. Nerspedia, 2(1), 27–32
Padila, P., Lina, L. F., Febriawati, H., Agustina, B., & Yanuarti, R. (2018). Home Visit Berbasis Sistem Informasi Manajemen Telenursing. Jurnal Keperawatan Silampari, 2(1), 217–235. https://doi.org/10.31539/jks.v2i1.305
Pranata, L., Koerniawan, D., & Daeli, N. E. (2019). Efektivitas ROM terhadap Gerak Rentang Sendi Lansia. Proceeding Seminar Nasional Keperawatan, 110–117
Rabelo, S. E. R., Cavalcanti, A. C. D., Caldas, M. C. R. G., Lucena, A. de F., Almeida, M. de A., Linch, G. F. da C., da Silva, M. B., & Muller-Staub, M. (2016). Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC). Journal of Clinical N, 26, 379–387. https://doi.org/10.1111/jocn.13387
Setyaningrum, E. E., Nurjannah, I., & Rustiyaningsih, A. (2019). Effect of NANDA-I, NIC, and NOC Documentation System Training on Quality of Nursing Care Documentation in The Perinatal Ward of Yogyakarta Regional Public Hospital. Belitung Nursing Journal, 5(2), 180–191. https://doi.org/https://doi.org/10.33546/bnj.770
Stonehouse, D. (2017). Understanding the Nursing Process. British Journal of Healthcare Assistants, 11(8), 388–391
Xiao, S., Widger, K., & Tourangeau, A. (2017). Nursing Process Health Care Indicators: A Scoping Review of Development Methods. Journal of Nursing Care Quality, 32(1), 32–39. https://doi.org/10.1097/NCQ.0000000000000207
Copyright (c) 2020 Dheni Koerniawan, Novita Elisabeth Daeli, Srimiyati Srimiyati
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
