Nursing Process Documentation among Nursing Students

Abstract

OBJECTIVE: This study aimed to determine the ability to document the nursing process among Nursing Professional Education students at the Faculty of Nursing, Universitas Syiah Kuala. METHODOLOGY: A Quantitative and cross-sectional study was applied to this research. Research instruments consisting of demographic data and a Knowledge questionnaire about documenting the nursing process were used to gain data among nursing students. Sixty-one nursing students were recruited using a questionnaire. The analysis of the data involved the use of univariate statistics. RESULTS: According to the study, 81.97% of nursing students had low knowledge of nursing process documentation. The results for each sub-variable regarding nursing assessment were 72.13%, nursing diagnosis 57.38%, nursing implementation 63.93%, and 78.69% of nursing evaluations were in the low category. Meanwhile, 57.38% of the nursing plan was in the high category. CONCLUSION: It is recommended that educational institutions and Nursing Professional Education students evaluate and improve their knowledge and skills regarding the nursing process and documentation under the Indonesian Hospital Accreditation Standard, with the hope that the understanding during the learning phase of the Bachelor of Nursing Education, the implementation of Nursing Professional Education in hospitals, and graduate competency when working are all connected.

Keywords

• nursing documentation
• nursing process
• nursing student