Implementation of Nursing Care Documentation Based on Indonesian Nursing Care Standards (SDKI, SLKI, and SIKI) in Hospitals

Nursing documentation is a description of the actions given by nurses to patients in nursing care. This documentation consists of assessment, diagnosis, outcome, intervention, implementation, and evaluation. Nursing documentation should be evaluated in relation to its application in providing nursing care. There is still diversity in formulating nursing diagnoses due to the variety of nursing education, knowledge of nurses, and even differences in the reference standards used. Nurses at Kaliwates General Hospital Jember have different backgrounds from different educational institutions. Training is needed in providing nursing care, especially in the formulation of nursing diagnoses. The purpose of this service is to increase knowledge and skills as well as to apply the SDKI, SLKI, and SIKI books in the preparation of nursing documentation. This service method is by collecting information related to the knowledge and skills of nurses about the application of the SDKI, SLKI, and SIKI; training by providing materials; mentoring; and evaluating the application of this book in the nursing care documentation process.


Introduction
The importance of documentation in nursing as a form of duty and responsibility in reporting services cannot be overstated.This aims to become an ongoing issue, so that documentation can represent the quality of nursing services provided (Jaya & Rasmiati, 2019).As the profession that provides the most services in hospitals, nurses are obliged to provide excellent and professional service.Professional context refers to behavior based on standards of nursing practice (Supratti and Ashriady, 2018).
The standards previously used in documenting nursing care were based on global standards, namely NANDA standards for diagnosis, NIC for interventions, and NOC for outcomes.The results of nursing interventions and diagnoses have not been able to answer the problems faced by patients in Indonesia (Puji Atmanto & Rofii, 2020).
Adoption of global standards as professional recommendations is a desirable policy, and is supported by standards regulations and research findings.Based on empirical studies, it is believed that the proposal will resolve all existing documentation problems, although other nursing issues remain unresolved.This is due to the fact that different research can come from many factors, such as Indonesia's ethnically and culturally diverse population (Suryono and Nugroho, 2020).
As a nursing professional organization, the Indonesian National Nurses Association (PPNI) has produced standards that serve as guidelines for nurses in the nursing process and refer to documentation standards as health service providers.These standards consist of the Indonesian Nursing Diagnosis Standards (SDKI) (SDKI DPP PPNI Working Group Team, 2017), Indonesian Nursing Outcome Standards (SLKI) (SLKI DPP PPNI Working Group Team, 2019), and Indonesian Nursing Intervention Standards (SIKI) (SIKI Working Group Team DPP PPNI, 2018).
Based on the results of observations and assistance in completing nursing documentation at RSU Kaliwates, there are still quite a lot of nurses who do not understand the SDKI, SLKI and SIKI standards for nursing documentation.Therefore, the mentoring function in educating nurses to complete nursing documentation is very important so that it can increase the knowledge and quality of nurses in completing nursing documentation.

Identification of Problems
Based on this background, the community service implementation team focuses on implementing diagnoses, outcomes and interventions based on the SDKI, SLKI and SIKI in the nursing documentation process provided in the management of nursing care.

Participant Recruitment
Participants in this activity were all nurses at Kaliwates Regional Hospital.Before carrying out service activities, the team conducted interviews with the result that nurses had never received socialization or training in using the SDKI, SLKI and SIKI books to create nursing documentation.

Location and Time
All training classes will be held at RSU Kaliwates during February 2022.Training will be held in the grounds of RSU Kaliwates which is fully equipped for three days of training.This accommodation is also equipped with audio-visual equipment which is useful for delivering effective lectures.

Training materials
The material required for this service is that participants are asked to prepare SDKI, SLKI and SIKI books, which are used as references in the training.

Training Methods
The method used is as follows:

a. Data collection
Extracting information regarding the level of knowledge of nurses regarding the use of SDKI, SLKI and SIKI books by conducting a pre-test.

b. Training
The training method functions to convey theories and concepts that are very principled and important for service participants to understand and master.The training was given for three days in the form of providing material on the use of SDKI, SLKI and SIKI books.
After training, a post-test was given.

c. Accompaniment
Assist nurses in carrying out documentation.

d. Evaluation
The final activity of this service is evaluating knowledge and skills in applying the SDKI, SLKI and SIKI books.Evaluation is carried out by direct observation of the documentation carried out by the nurse.

Training Assessment
The success of this exercise depends on participant participation.The exam questions are made easy, and we only ask about basic knowledge of the subjects presented by the tutor.Participants were asked to answer a total of 21 questions.Using the knowledge level and age of the participants as a guide, simple questions were prepared.To facilitate analysis and understanding, we converted the correct answer scores to a scale ranging from 0 to 100.All accurate answers will receive 100 out of 21 questions, or 4.76 points for each correct answer.

Results and Discussion
Training activities provide complete solutions for preparing nursing care documentation.This increases nurses' awareness to carry out documentation correctly and in accordance with Indonesian nursing standards.The following is a discussion of community service activities.

Preparation Phase
The first stage in data collection on the first day related to Kaliwates Hospital's need for documentation based on SDKI, SLKI and SIKI.The discussion process can be seen in Figure 1.

Knowledge transfer
The main activity on the second day of this training was the transfer of knowledge to the participants.Before the training begins, participants are given a pretest which can be seen in Figure 2 (a).Then we focused on conveying applicable information about documenting nursing care based on SDKI, SLKI, and SIKI.Through this activity, tutors socialize the use of SDKI, SLKI and SIKI books which are used as references in documenting nursing care.This book provides participants with an understanding of a nurse's knowledge in carrying out their duties.
This training explains the role of developing critical thinking of nurses in analyzing all patient needs which must be prepared, implemented and evaluated by a nurse during the patient care process.interactive learning can be seen in Figure 2    diagnoses, outcomes and interventions that must be determined based on the conditions they face in the hospital, in addition to knowing the various events that occurred.By presenting the material, it is hoped that participants will be able to trigger the expected increase in knowledge.
During implementation with direct problems, participants know where they can find the right information and it can help increase their knowledge regarding IDHS, SLKI and SIKI.

Conclusion
Nurses must be able to understand and appropriately adapt the SDKI, SLKI, and SIKI standards to hospital service needs.So that Kaliwates RSU nursing services can continue workshop activities by adapting standards to hospital conditions and carrying out role plays in each room to speed up nurses' adaptation to the implementation of Indonesian Nursing Care Standards.
Through this training, nurses increase their knowledge in documenting nursing care in accordance with the SDKI, SLKI, and SIKI.This outreach combines classroom teaching with field work.Apart from being presented by academics, the implementation process also included direct feedback from all nurse practitioners who took part in the program.This strategy increases nurses' understanding of the subjects taught.This goal will be the first step toward planning and documenting nursing care in a way that works well.
To maintain these community service results, we propose further community service opportunities involving ongoing support of activities, which will involve several parties.This activity will be further enhanced if it is followed by additional training for nurses, such as increasing continuous productivity performance.
Presence and conversational engagement are indicators of good training.On each training day, participants are asked to fill out an attendance form.Participants' pre-and post-tests are other instruments used for training evaluation.This instrument functions to evaluate participants' understanding of lecture material and field training.Each participant is required to take a pretest at the beginning of the lesson.Lastly, they are required to complete the posttest.With the same questions on the pre-test and posttest, we can see how well participants understand the training material.20

Figure 1 .
Figure 1.Data collection stage on the first day regarding Kaliwates Regional Hospital's need for documentation based on SDKI, SLKI and SIKI (b).After the material delivery process, Mentoring participants were given training to prepare nursing care documentation based on SDKI, SLKI and SIKI, the activities can be seen in Figure 2 (c).

Figure 2 .
Figure 2. Implementation of the second day (a) Pretest (b) material presentation (c) evaluation This case trigger is obtained from hospital patient data so that participants can prepare a document containing various