Pengetahuan Dan Pelaksanaan Dokumentasi Perawat Terhadap 3S SDKI, SIKI Dan SLKI
Abstract
Background: Nursing care standards are inherently linked to the nursing process, which forms the core responsibility of nurses in delivering patient care. This process includes assessment, diagnosis, planning, implementation, and evaluation. The aim of this study is to assess nurses' knowledge and documentation practices related to the 3S components—SDKI, SLKI, and SIKI—at RS Prof. Dr. Tabrani Pekanbaru. Methods: This study employed a quantitative, descriptive research design using a questionnaire. The population consisted of all 40 nurses working at RS Prof. Dr. Tabrani Pekanbaru, and the entire nursing staff was included as the sample. Results: The findings revealed that only 4 respondents (10%) demonstrated good knowledge of SDKI, SIKI, and SLKI. A majority of 20 respondents (50%) had moderate knowledge, while 16 respondents (40%) showed limited understanding of nursing care based on SDKI, SIKI, and SLKI. Conclusion: Based on these results, it can be concluded that the nursing staff has not yet fully comprehended nursing care using the SDKI, SIKI, and SLKI standards. It is recommended that the institution conduct socialization and simulation activities to improve documentation practices aligned with these standards. This initiative is expected to better prepare nurses for applying these standards in healthcare facilities.
References
Ardiana. (2019). Persepsi Perawat Terhadap Pelaksanaan Pendokumentasian Keperawatan di Irj RSUP Fatmawati, Jakarta.Awaliyani, V. A., Pranatha, A., & Wulan, N. (2021). Pengaruh penggunaan buku SDKI, SLKI dan SIKI terhadap peningkatan pengetahuan perawat dalam membuat dokumentasi asuhan keperawatan berbasis SDKI, SLKI dan SIKI di Rumah Sakit KMC Kuningan Tahun 2021. Journal of Nursing Practice and Education, 2(1), 22–32. https://doi.org/10.34305/jnpe.v2i1.334
Jaya, K., Rusli, A., & Chairani, S. (2019). Gambaran pendokumentasian asuhan keperawatan di ruang rawat inap RSUD Buton Utara. Jurnal Keperawatan, 2(3), 27–36.Jurnal Keperawatan Merdeka (JKM), Volume5Nomor 2, November2025118Kurniawandari, E., & Fatimah, F. S. (2017). Implementation of Documentation of Nursing Care in Wates Hospital. Jurnal Ners dan Kebidanan Indonesia (JNKI). Diakses dari: https://ejournal.almaata.ac.id/index.php/JNKI/article/view/955
Manuhutu, F., Novita, R. V. T., & Supardi, S. (2020). Pendokumentasian asuhan keperawatan oleh perawat pelaksana setelah dilakukan pelatihan supervisi kepala ruang di Rumah Sakit X, Kota Ambon.Jurnal Ilmiah Perawat Manado (Juiperdo), 8(1), 171–191. https://doi.org/10.47718/jpd.v8i01.1150
Noorkasiani, N., Gustina, R., & Siti Maryam. (2015). Faktor‑Faktor yang Berhubungan dengan Kelengkapan Dokumentasi Keperawatan. Jurnal Keperawatan Indonesia, 18(1), 1–8. Diakses dari: https://jki.ui.ac.id/index.php/jki/article/view/391
Nora,S., Hernawati, I., & Astuti, A. W. (2023). Hubungan Pengetahuan dengan Dokumentasi Asuhan Keperawatan Berdasarkan SDKI, SIKI dan SLKI. Jurnal Informasi Kesehatan Indonesia, 9(2), 102–108. https://jurnalhost.com/index.php/jika/article/view/197Notoatmodjo, S. (2018). Promosi Kesehatan dan Perilaku Kesehatan (Edisi Revisi). Jakarta: Rineka Cipta.
Rajacich, D., Kane, D., Williston, C., & Cameron, S. (2013). If they do call you a nurse, it is always a “male nurse”: Experiences of men in the nursing profession. Nursing Forum, 48(1), 71–80. https://doi.org/10.1111/nuf.12008
Rezkiki, F., & Ilfa, A. (2022). Pengaruh supervisi terhadap kelengkapan dokumentasi asuhan keperawatan di ruangan non bedah.REAL in Nursing Journal, 1(2), 70–82. https://doi.org/10.32883/rnj.v1i2.322
Rosnawati, D., et al. (2023). Hubungan Faktor Individu dengan Dokumentasi Asuhan Keperawatan.Jurnal Penelitian dan Pengkajian Ilmu Keperawatan, https://jurnal.globalhealthsciencegroup.com/index.php/JPPP/article/view/1871.
Siba Wadan, F., et al. (2023). Pengaruh Supervisi dan Pengetahuan terhadap Kepatuhan Dokumentasi Asuhan Keperawatan. Jurnal Ilmiah Manajemen Terapan, https://dinastirev.org/JIMT/article/view/1536.
Sulistyawati, E., & Susmiati, S. (2021). Hubungan Pelatihan dengan Pengetahuan dan Penerapan Dokumentasi Asuhan Keperawatan Berdasarkan SDKI, SIKI dan SLKI. Prosiding Seminar Nasional Kesehatan, 3(1), 112–118. https://jurnal.unej.ac.id/index.php/prosiding/article/view/26691
Suryono, S., & Nugroho, C. (2020). Kompetensi Perawat Mendokumentasikan Diagnosis Keperawatan Berdasarkan Standar Diagnosis Keperawatan Indonesia (SDKI).Jurnal ILKES(Jurnal Ilmu Kesehatan), 11(1), 233-238.
Tasew H, Mariye T, Teklay G.(2019). “Nursing Documentation Practice and Associated Factors among Nurses in Public.” . . BMC Res Notes [Internet 1(hal 1–6):43.
Trisno, T., Nursalam, N., & Triharini, M. (2020). Analisis Ketepatan Pelaksanaan Proses Asuhan Keperawatan di RS Swasta Jawa Timur. News Universitas Airlangga. Diakses dari: https://news.unair.ac.id/id/2020/08/11/analisis-ketepatan-pelaksanaan-proses-asuhan-keperawatan/
Wulandini S, (2023). Enabling Faktors Yang Hubungan Dengan prilaku Pendokumentasian Asuhan Keperawatan Di Rsj Tampan. Pekambaru.Yang, R., et al. (2024). Gender-related differences in the scope of nursing practice in geriatric settings. BMC Nursing. https://doi.org/10.1186/s12912-024-02516-5
Copyright (c) 2025 JKM : Jurnal Keperawatan Merdeka
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work
