Healthcare Nursing Journal
Vol. 5 No. 2 (2023): HealthCare Nursing Journal

Nursing Care Documentation Analysis Based on Standard Nursing Care Evaluation Instruments

Usman Sasyari (Nursing Department, Faculty of Health,Universitas Muhammadiyah Tasikmalaya, Indonesia)
Fitri Nurlina (Nursing Department, Faculty of Health,Universitas Muhammadiyah Tasikmalaya, Indonesia)
Yuyun Solihatin (Nursing Department, Faculty of Health,Universitas Muhammadiyah Tasikmalaya, Indonesia)



Article Info

Publish Date
28 Jul 2023

Abstract

The completeness of nursing care documentation has been set at a minimum standard of 85%. This is to show the patient's condition which is seen not only from the level of pain but also from the type, quality and quantity of services that have been provided by nurses in meeting patient needs. This study aims to analyze the completeness of nursing care documentation based on SAK evaluation instruments. The method used is descriptive with a documentary study using SAK. The results showed that the completeness of the assessment was 100%, the diagnosis was 90%, the intervention was 86.6%, the implementation was 100%, and the progress record was 100%. It is recommended that there be continuous and consistent evaluation by the field of nursing on nursing care documentation.

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Journal Info

Abbrev

healtcare

Publisher

Subject

Nursing

Description

Healthcare Nursing Journal merupakan salah satu Journal Elektronik yang dikelola oleh Program Studi Keperawatan Universitas Muhammadiyah Tasikmalaya. Jurnal ini terbit secara berkala, dan merupakan fasilitas bagi civitas akademika pada bidang kesehatan dan keperawatan. Memuat berbagai karya tulis ...