Documentation of Nursing Care in Majauleng Health Centre Wajo District, Indonesia

Isymarni Syarif, Besse Munawara and Abdul Gafur
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Isymarni Syarif: Departement of Health Sciences, Islam University of Makassar
Besse Munawara: Departement of Health Sciences, Islam University of Makassar
Abdul Gafur: Departement of Public Health, University of Pejuang Republic Indonesia

International Journal of Research and Scientific Innovation, 2021, vol. 8, issue 3, 22-26

Abstract: Nursing documentation is a means of communication to other health teams regarding client status. Nursing documentation is very important to convey information about client status, help nurses communicate in the results of observations, decisions, actions, and results of the actions of nurses from clients. The aim of this research is to find out the description of the application of nursing care in nursing documentation at the Majauleng Community Health Center. The research method is consecutive sampling technique, with a sample of 33 respondents at Majauleng Public Health Center, Wajo Regency, with the type of research is quantitative, the research design used is descriptive. The results obtained were the application of nursing care with good categories as many as 22 respondents (66.7%), while the application of nursing care with poor categories was 11 respondents (33.3%). Conclusion: Documentation of nursing care with the 3S approach (SDKI, SLKI, SIKI) at the Majauleng Health Centre Wajo District Indonesia, has basically been done well by 66.7%, but there are still nurses who do not understand the documentation of nursing care. So it takes a case discussion reflection to all nurses to improve their skills and knowledge in documenting nursing care. This must be supported by the availability of facilities and infrastructure such as the format of nursing care and it is hoped that the support of the Health Centre leadership in monitoring nursing care documentation is expected.

Date: 2021
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