Optimalisasi Penggunaan SDKI, SLKI, dan SIKI dalam Penyusunan Dokumentasi Keperawatan di Ruang IGD RS Tipe B Kota Malang

Indri Wahyuningsih, Risa Herlianita
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Abstract

Nursing documentation carried out by nurses in carrying out the nursing process includes components of assessment, data analysis, nursing diagnosis, intervention, nursing implementation and evaluation. The nursing process is an inseparable part of nursing care services. A nursing process that is carried out well is one of the indicators for determining the assessment of the quality of nursing care services in a hospital. One component to be able to realize quality nursing care is the nursing documentation aspect. Good documentation is beneficial for patients, nurses and hospitals and can be used as a guide to provide quality services. Nursing documentation carried out by partners in using the SDKI, SLKI and SIKI guidelines has not been carried out optimally and well integrated. The output resulting from this service activity is an increase in nurses' understanding of the use of SDKI, SLKI and SIKI so that it can be applied more optimally, as well as the preparation of emergency nursing documentation forms based on SDKI, SLKI and SIKI.
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马朗市 B 类医院急诊室护理文件编制中对 SDKI、SLKI 和 SIKI 的优化使用
护士在执行护理程序时进行的护理记录包括评估、数据分析、护理诊断、干预、护理实施和评价等部分。护理程序是护理服务不可分割的一部分。护理流程执行得好坏,是判断医院护理服务质量评价的指标之一。护理记录是实现优质护理服务的一个环节。良好的记录对患者、护士和医院都有好处,可以作为提供优质服务的指南。合作伙伴在使用 SDKI、SLKI 和 SIKI 指导原则时所进行的护理文件编制工作并没有达到最佳效果,也没有得到很好的整合。这项服务活动的成果是提高了护士对 SDKI、SLKI 和 SIKI 的使用的理解,从而使其得到更好的应用,并根据 SDKI、SLKI 和 SIKI 编制了紧急护理文件表格。
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