PENGEMBANGAN FORMAT DOKUMENTASI ASUHAN KEPERAWATAN BERBASIS STANDARDIZED NURSING LANGUAGE (SNL) NANDA-I, NOC DAN NIC DI RUANG RAWAT INAP

  • made ermayani Akper Dirgahayu Samarinda
  • aprilia nuryanti Akademi Keperawatan Dirgahayu Samarinda
Keywords: format dokumentasi asuhan keperawatan, NANDA-I, NOC dan NIC

Abstract

Abstract

The extent area of nursing, the number of nursing school, and the place of nursing service in Indonesia or overseas will need a nursing language classification system that is standardized (Standardized Nursing Language/SNL) to formulate nursing diagnoses, purpose, and intervention nursing. This research aims to develop documentation format based on based SNL- Nanda I, NOC and NIC in the surgical medical room. The first step is exploration documentation nursing, the second stage are test, try, and evaluation. Purposive sampling was used to obtain participants. Method collecting data used FGD, sheet of observation quality of nursing care format, and quality of documentation nursing. The first FGD involved six nurses, the second FGD involved six nursing management of hospital and 11 nurses from medical surgery room. The result was good category for all indicators (functionality 82.39; efficiency 85.80; usability 82.95) and documentation nursing care quality using SNL NANDA-I, NOC and NIC showed that all indicators was good (completeness >86.16; accuracy >90; relevance >91.36; novelty 100). Hospital needs to consider the application of documentation format using nursing language standarized with NANDA-I, NOC and NIC at all room. Nurses need to improve ability in using SNL NANDA-I, NOC and NIC appropiately.

Keywords: nursing care documentation format, NANDA-I, NOC and NIC

 

Abstrak

Luasnya  area  keperawatan  dan  banyaknya  institusi  pendidikan  serta  tempat pelayanan  keperawatan  di  Indonesia  maupun  luar  negeri,  maka  akan membutuhkan  suatu  sistem  klasifikasi  bahasa  keperawatan  yang  terstandar (Standardized  Nursing  Language/ SNL)  untuk  merumuskan  diagnosis keperawatan,  tujuan  dan  intervensi  keperawatan. Tujuan penelitian untuk mengembangkan format dokumentasi berdasar SNL Nanda-I, NOC dan NIC di ruang perawatan medikal medah. Tahap pertama adalah eksplorasi dokumentasi keperawatan dan tahap kedua adalah uji coba dan evaluasi. Purposive sampling digunakan dalam pemilihan partisipan. Metode pengumpulan data melalui FGD, lembar observasi mutu format asuhan keperawatan dan mutu dokumentasi keperawatan. FGD pertama melibatkan enam perawat pelaksana, FGD kedua melibatkan enam dari jajaran manajemen keperawatan RS dan 11 orang perawat dari ruang perawatan medikal bedah dalam uji coba format. Mutu format asuhan keperawatan dalam kategori baik untuk semua indikator (functionality 82,39; efficiency 85,80; usability 82,95) dan mutu dokumentasi asuhan keperawatan menggunakan SNL NANDA-I, NOC dan NIC menunjukkan semua indikator dalam kategori baik (kelengkapan >86,16; akurasi >90; relevansi >91,36; kebaruan seluruhnya 100). RS perlu mempertimbangkan penerapan format dokumentasi menggunakan bahasa standar keperawatan menurut NANDA-I, NOC dan NIC di semua ruang perawatan. Perawat perlu terus menggali kemampuan dalam menggunakan SNL NANDA-I, NOC dan NIC yang aplikatif sesuai setting pelayanannya.

Kata kunci: format dokumentasi asuhan keperawatan, NANDA-I, NOC dan NIC

 

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Published
2017-11-30
How to Cite
ermayani, made, & nuryanti, aprilia. (2017). PENGEMBANGAN FORMAT DOKUMENTASI ASUHAN KEPERAWATAN BERBASIS STANDARDIZED NURSING LANGUAGE (SNL) NANDA-I, NOC DAN NIC DI RUANG RAWAT INAP. MNJ (Mahakam Nursing Journal), 2(2), 50-61. Retrieved from https://ejournalperawat.poltekkes-kaltim.ac.id/ojs/index.php/nursing/article/view/97
Issue
Vol 2 No 2 (2017): Nov 2017
Section
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