The Implementation of Nursing Diagnosis Based on Indonesian Nursing Diagnosis Standard: Retrospective Study

Nursing documentation provides evidence of patient care quality and facilitates efficient communication between healthcare providers. Although it has been discussed extensively in various scholarly article, there is still diversity in formulating nursing diagnoses nursing documentation in Indonesia persists as a challenge. The objective of this study is to describe the implementation of nursing documentation is being implemented following Indonesian nursing diagnosis standards in the inpatient ward. A quantitative design with a retrospective approach was used, in which 225 medical records from Banda Aceh hospitals, were obtained and assessed. The Nursing documentation were randomly selected based on hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analysed using univariate statistics. The results revealed that the implementation of nursing documentation following Indonesian nursing diagnosis standards in the inpatient ward was sufficient category (54.7%). The continuous direction, control, and evaluation of nursing activities and documentation should be done by a nurse manager. It is important to maintain good quality in nursing activities to enhance patient satisfaction, safety, and cost-effectiveness photoaging.