Evaluasi Kualitas Dokumentasi Asuhan Keperawatan Metode NNN (Nanda, NOC dan NIC) pada Keperawatan Neonatus: Studi Deskriptif Observasional Dokumentasi Mahasiswa Ners

  • Sholihatul Amaliya Departemen Keperawatan, Fakultas Ilmu Kesehatan, Universitas Brawijaya
  • Nurona Azizah Universitas Brawijaya https://orcid.org/0000-0003-4994-5817
  • Septi Dewi Rachmawati Universitas Brawijaya
  • Rinik Eko Kapti Universitas Brawijaya
  • Alvin Fitri Hendika Universitas Brawijaya
  • Nindy Claudia Abrianti Universitas Brawijaya
Keywords: diagnosis; intervention; nursing student; outcome; quality of documentation


Quality of nursing care documentation is important for building effective communication between nurses and other health professionals and is also related to the quality of nursing care intervention. However, research that examines the quality of nursing care, especially in the nursing care documentation of prospective nurses (nursing student) has not been carried out. This study aims to assess the quality of nursing care documentation from nursing students in the neonatal nursing area. This study used a descriptive observational research design with a cross-sectional approach from secondary data from 40 nursing care documentations of students at the learning stage of the Nurse profession program by purposive sampling. The criteria used were documentation of care from infants aged 0 days to 28 days and treated in the perinatology room during the student practice period with the exclusion criteria of incompletely nursing documentation. The quality of nursing care documentation was assessed by Q-DIO modified observation sheet. The results showed that the outcomes of nursing care had the highest score followed nursing diagnoses and nursing interventions (93.75; 86.7; and 81.25). The conclusion of this study is that the of nursing intervention gets the lowest score compared to nursing diagnoses and outcomes, therefore, in the learning process of the Nurse profession program it is necessary to emphasize holistic and comprehensive nursing interventions. Further research can be carried out on nursing care documentation using the 3S method (SDKI, SLKI and SIKI)