OVERVIEW OF THE IMPLEMENTATION OF NURSING CARE IN NURSING DOCUMENTATION IN PHC MAJAULENG WAJO DISTRICT

GAMBARAN PENERAPAN ASUHAN KEPERAWATAN DALAM PENDOKUMENTASIAN KEPERAWATAN DI PUSKESMAS MAJAULENG KABUPATEN WAJO

Abstract

Nursing documentation is a means of communicating to other health teams regarding the client's status. Nursing documentation is very important for conveying information about the client's status, helping nurses communicate the results of observations, decisions, actions, and the results of the nurse's actions from clients. The aim of the research is to find out an overview of the application of nursing care in nursing documentation at the Majauleng Community Health Center. The research method is a consecutive sampling technique, with a sample of 33 respondents at the Majauleng Community Health Center, Wajo Regency, with the type of research being quantitative, the research design used is descriptive. The research results obtained were that the application of nursing care in the good category was 22 respondents (66.7%), while the application of nursing care in the poor category was 11 respondents (33.3%). Conclusion of the description of 3S nursing care standards (SDKI, SLKI, SIKI) in nursing documentation at the Majauleng District Health Center. Wajo is in the good category. It is recommended that the implementation of increased nursing care training be based on 3S (SDKI, SLKI, SIKI) which is one of the competencies that can be a reflection of the quality of health services.

Keywords: Nursing care, nursing documentation