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Emi Eliya Astutik
Department of Fundamental and Management in Nursing, Universitas dr. Soebandi, Jember, Indonesia
Nursing

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Application of nursing terminology based on the Indonesian nursing standards (diagnosis, outcome, and intervention) on the quality of filling out documentation Mahmud Ady Yuwanto; Emi Eliya Astutik; Rizki Eko Prasetyo
Jurnal Keperawatan Vol. 14 No. 02 (2023): July
Publisher : University of Muhammadiyah Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.22219/jk.v14i02.24106

Abstract

Introduction: So as to account for the implementation, Indonesian nurses must be able to provide comprehensive, independent in nursing care. Objectives: This study aims to determine how using standard nursing terminology affects the quality of nursing documentation. Methods: This study employs a quantitative approach and a quasi-experimental design with non-equivalent groups and no control group. All room nurses at the Kaliwates General Hospital in Jember participated in the research. Sampling strategy based on total sampling using the non-parametric Wilcoxon test, a questionnaire was analyzed as the instrument. Results: The p-value of the results was 0.000. After training and assistance with filling out nursing documentation, the quality score for filling out nursing documentation improves. High-quality nursing documentation promotes structured, consistent, and successful communication. Inadequate nurse-to-nurse communication causes care discontinuity and mistakes. Implementing standard Indonesian nursing terminology has several ramifications. Conclusions: Standard nursing language terminology has a significant impact on improving the quality of nursing documentation based on Indonesian Nursing Standards (diagnosis, outcome, and intervention). Hospitals are expected to establish nursing documentation standards and conduct regular monitoring.
Co-Authors Mahmud Ady Yuwanto Rizki Eko Prasetyo