The Application of Electronic Medical Record-Based Nursing Care Documentation in Improving the Effectiveness of Nursing Services
DOI:
https://doi.org/10.56294/mw2025889Keywords:
Nurses, Documentation, SDKI, SLKI, SIKIAbstract
Introduction : Incomplete nursing documentation can have an impact on client safety and the quality of service provided to clients, with the risk of miscommunication between nursing care providers and clients. The phenomenon occurring at the Community Health Center in Banyuwangi Regency is the non-implementation of SDKI, SLKI, and SIKI in documenting nursing care. So far, there has been no qualitative study in Indonesia related to nursing documentation using SDKI, SLKI, and SIKI. This study aims to explore further the documentation of nursing care using SDKI, SLKI, and SIKI at the Mojopanggung, Singotrunan, and Kelir Community Health Centers in Banyuwangi Regency.
Methods : This study used a qualitative method with a descriptive phenomenological approach. The number of participants consisted of 16 people with purposive sampling technique. Data collection used in-depth interviews, observation, and nursing documentation review techniques.
Results : The results of this study revealed three themes, namely that human resource development has not been optimal. The second theme is the challenges and obstacles faced by nurses in nursing documentation. The third theme is that the application of digital information systems has not been optimal, particularly the implementation of SDKI, SLKI, and SIKI documentation in electronic medical records.
Conclusions : The success of implementing digital-based nursing documentation depends not only on the availability of technological systems, but also on strengthening human resource capacity, effective supervision, and managerial support in managing workloads and improving information systems.
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Copyright (c) 2025 Sastrawati Desak Kadek, Susanti Dina NLP, Wahyuningsih Ni Luh Gde Nita Sri, Nuartini Ni Nyoman (Author)
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