157 

 

PENGEMBANGAN INSTRUMEN DIAGNOSIS & INTERVENSI KEPERAWATAN 

BERBASIS STANDARDIZED NURSING LANGUAGE  (NANDA-I, NOC, NIC)  

 

(Development of Nursing Diagnosis & Intervention Instrument Based on Standardized 

Nursing Language (Nanda-I, NOC,NIC))  

 

Diana Rachmania*, Nursalam*, Esti Yunitasari* 

*Magister Keperawatan Fakultas Keperawatan Universitas Airlangga 

Email: widiana1925@gmail.com 

 

 
ABSTRAK 

Pendahuluan: Dokumentasi keperawatan yang sesuai standar bahasa keperawatan (Standarized Nursing Language), masih 

merupakan masalah di dalam profesi perawat, khususnya keseragaman dalam penggunaan bahasa diagnosa dan intervensi 

keperawatan. Dibutuhkan suatu instrumen untuk bisa menghasilkan dokumentasi diagnosis dan intervensi yang baik. Tujuan 

dari penelitian adalah meyusun pengembangan instrument diagnosis dan intervensi keperawatan berbasis Standardized 

Nursing Language (NANDA-I, NOC, NIC). Metode: Desain penelitian ini adalah action reserach dilaksanakan dalam 2 

tahap. Populasi tahap 1 adalah 16 partisipan dan 9 sampel. Partisipan dan sampel dipilih dengan tehnik purposive sampling 

dengan partisipan sebanyak 15 dan sampel 7. Populasi tahap 2 adalah 13 partisipan dan 8 sampel. Partisipan dan sampel 

dipilih dengan tehnik tehnik purposive sampling dengan partisipan sebanyak 13 dan sampel 8. Analisa data menggunakan 

analisis deskriptif, analisis statistik Product Moment Pearson Correlation untuk uji validitas dan cronbach alpha untuk uji 

reliabilitas. Hasil: Pengembangan instrumen diagnosis dan intervensi  keperawatan yang disusun berdasarkan hasil kegiatan 

FGD dinyatakan valid dan reliable. Diskusi: Setiap Rumah Sakit diharapkan selalu rutin dalam mengevaluasi instrumen 

diagnosis dan intervensi keperawatan yang sesuai standar dan  kebijakan yang berlaku agar tercipta dokumentasi 

keperawatan yang berkualitas 

Kata Kunci: Standarized Nursing Language, NANDA-International, Nursing Outcomes Classification, Nursing Interventions 

                           Classification 

 

 

ABSTRACT 

Introduction: Nursing documentation appropriate standards of nursing language (Standarized Nursing Language), was still a 

problem in the nursing profession, especially uniformity in using nursing diagnoses and interventions language. Instrument 

were needed to produce a good quality of nursing diagnosis and intervention’s documentation. The purpose of the research 

was to develop nursing diagnosis and interventions instrument based on the Standardized Nursing Language (NANDA-I, 

NOC, NIC). Methods: This study was action reserach carried out in 2 phases. The population of phase 1 were 16 participants 

and 9 samples. Participants and samples selected by purposive sampling techniques with participants were 15 and samples 

were 7. The population of phase 2 was 13 participants and 8 samples. Participants and samples selected by purposive 

sampling technique with participants were 13 and samples were 8. Analyze data using descriptive analysis, statistical analysis 

using Pearson Product Moment Correlation for validity test and Cronbach alpha for reliability test. Results: Development of 

nursing diagnostic and interventions instruments, that was formulated based on Focus Group Discussion, declared valid and 

reliable. Discussion: Each hospital was expected to always routinly evaluate the nursing diagnosis and interventions 

instrument as a standard and policies in order to create a quality nursing documentation 

Keywords: Nursing Diagnosis, Nursing Intervention, Standardized Nursing Language, NANDA-International, Nursing 

                  Outcomes Classification, Nursing Interventions Classification 

 

INTRODUCTION 

Documentation appropriate with standards 

nursing language was still a problem in the 

nursing profession, especially uniformity in 

using nursing diagnoses and nursing  

interventions language. In order to produce a 

good nursing documentation, need to be 

supported with good quality of nursing 

instrument . The phenomena that often occurs 

is nursing documentation instrument especially 

nursing diagnoses and nursing interventions 

instrument is still not in accordance with the 

rules of Standardized Nursing Language 

(NANDA-I, NOC, NIC) one of which occurred 

in Amelia Pare Hospital. 

The use of the language contained in the 

nursing diagnosis instrument in RS Amelia 

Pare were less appropriate to the use of 

language in NANDA-I (North America 

Nursing Diagnoses Association- International), 

writing outcomes and action plans on nursing 

interventions instrument was already there, but 

it was still not fully describe all activities 

performed by nurses in planning actions. It was 

also necessary that an instrument need to be   

mailto:AirlanggaEmail:%20widiana1925@gmail.com
mailto:AirlanggaEmail:%20widiana1925@gmail.com


Jurnal Ners Vol 11 No 2 Oktober 2016: 157-163 

158 

 

standardized in common nursing language 

usage among nurses with nurse one another so 

as to create a good communication process 

which was reflected from the nursing documentation 

process contained in RS Amelia Pare.  

Data collection on the nursing documentations in 

Teratai room RS Amelia Pare conducted by researchers 

at the date of October 4, 2015 by interview and 

observation. The NUM of Teratai Room said that 

actualliy nurses knew that their task after implementation 

was documented, but only certain things such as TTV, 

injection drug delivery, and other routine activities that 

documented  in nursing instrument. Resut of interviews 

with four from the 13 nurses (30%), that the four 

nurses said that they had not much time to 

write in the instrument that has been provided 

for the number of actions that must be done to 

the patient instead of writing on the existing 

format/instrument. Documentation that has not 

been completed by a nurse is a diagnosis and 

intervention, nursing implementation, and 

evaluation. The results of observations 

conducted by researchers of the diagnosis and 

intervention instruments that contained a check 

list format that facilitates nurses in selecting 

appropriate nursing diagnoses. But there are not 

appropriate with  NANDA-I nuring diagnoses. One 

sheet format consists of a variety of purposes and 

no nursing outcomes and the action plans 

mixed together with one another diagnosis that 

made care plan was less specific and less 

complete. 

Nursing documentation seized almost 

50% of his time nurse per shift (Gugerty et al, 

2007). Most nurses in the clinical order, did 

not do a complete documentation. The reason 

why nurses did not do nursing documentation 

was most nurses prefer to spend their time to 

perform actions on the patient and not 

documenting it. Factors of employment, 

training and workload according to Siswanto, 

MH., Hariyati, TS., (2013) was a factor that can 

affect the completeness of the documentation of 

nursing. Work environment, high workload, 

and the difficulty of charging time format 

documentation contributes to lack of quality of 

nursing documentation (Okaisu, E.M., 

Kalikwani, F., Wanyana, G. & Coetzee 2014) 

The concept of the solutions developed 

in this research was to develop nursing 

diagnoses and interventions instruments based 

on the Standardized Nursing Language (SNL) 

in a format in the form of check list (√) in 

patients with cases Diabletes Mellitus in order 

to facilitated nurses in filling nursingdiagnoses 

and interventions instrument and efficiency 

time of nursing care. Nursing diagnosis instrument was 

made according to the NANDA-I (North America 

Nursing Diagnoses Association- International), 

and for nursing interventions, nursing outcome 

according to the NOC (Nursing Outcomes 

Classification), and the selection of action plans 

according to the NIC (Nursing Interventions 

Classification). The benefits of the use of standardized 

languages was to improve communication between 

nurses and other health care providers and 

patients, increase the visibility of nursing 

interventions, and improving data collection to evaluate the 

results of nursing care (Rutherford 2008) The 

strategy was increased knowledge and skills of 

nurses through socialization and training, as well as the 

practice of charging instrument nursing documentation in 

accordance stadardized nursing language. 

Development of  nursing diagnosis and 

intervention instrument based on Standardized 

Nursing Language (NANDA-I, NOC, NIC) 

was expected to improve the quality of nursing 

diagnosis and interventions. Based on the 

description that had been described previously 

so it need to be develop  nursing diagnosis and 

intervention instrument based on Standardized 

Nursing Language (NANDA-I, NOC, NIC). 

 

MATERIALS AND METHODS 

Design research was action research 

conducted in two phases. The first phase was 

the preparation of nursing diagnosis and 

intervention instrument so that the instrument 

developed valid and reliable, supported by 

statistical analysis using Pearson Product 

Moment Correlation test to determined the 

validity and Cronbach alpha test to determined 

the reliability and descriptive analysis. Phase 

two was the process of socialization and 

training in the used of instruments so that the 

nurses were able to use the nursing diagnosis 

and interventions instrument based on  Standardized 

Nursing Language (NANDA-I, NOC, NIC). 

Descriptive analysis was used to determined 

the frequency distribution of each sub-category 

variable. 

The population of the first phase of 

activities FGD consists of a field of nursing, 

nursing committee, NUM and the nurses. 

Participants in the focus group were selected 

based on purposive sampling technique. 

Participants in the FGD amounted to 15. The 

population of the first phase to test the validity 

and reliability is a nurse and the selection of  



Development of Nursing Diagnosis & Intervention Instrument (Diana Rachmania,dkk) 

159 

 

the sample using purposive sampling technique 

gained 7 nurses. The population of the second 

phase that used to evaluate the capability of 

nurses in the charging nursing diagnoses and 

intervention instrument based on Standardized 

Nursing Language (NANDA-I, NOC, NIC) 

was a nurses at Teratai Room and the selection 

of the sample using purposive sampling 

technique gained 8 nurses. The population of 

the second phase for FGD activities consist of 

nursing, nursing committee, NUM and the 

nurse at Teratai Room. Participants in the 

focus group were selected based on purposive 

sampling technique. Participants in the FGD 

amounted to 13 participant. 

Variables in this research was the development of 

nursing diagnosis and intervention instruments 

based on Standardized Nursing Language 

(NANDA-I, NOC, NIC). Phase 1 consisted of 

standard nursing diagnostic evaluation and 

assessment of nursing interventions used in 

hospital Amelia, drafting nursing diagnosis and 

intervention instrument through FGD (Focus 

Group Discussion), to test the validity and 

reliability of the instrument diagnosis and 

nursing interventions. Phase 2 consisted of 

filling training instruments based nursing 

diagnosis and intervention Standardized 

Nursing Language (NANDA-I, NOC, NIC), 

the evaluation of the ability of the nurse in 

charge of instruments and recommendations 

resulting from the study. 

Data processing at one phase consists of 

a descriptive analysis of the results of the 

evaluation standards for diagnosis and 

assessment of nursing interventions used in 

hospital diagnosis Amelia and drafting 

instruments and nursing interventions through 

FGD (Focus Group Discussion). Inferential 

analysis was carried out to test the validity 

with Pearson Product Moment Correlation test 

to determine the validity and Cronbach alpha 

test to determine the reliability of the 

provisions of the table r 0.754 (by 7 

respondents). The data processing phase 2 is 

done with descriptive analysis to determine the 

frequency distribution of each sub-category 

variable. 

 

RESULTS 

Results & Analysis Research phase 1 

Characteristics of 15 participants FGD is 

almost part of the participants (33%) were 

aged> 40 years, the entire pastisipan (100%) 

were women, almost half of the participants 

(46%) working time> 15 years, most of the last 

education is D3 of Nursing, and all participants 

(100%) is a permanent employee. This shows 

that the FGD participants is included in the 

category of productive age, with work 

experience long enough so that it can give an 

idea of the needs of the instrument nursing 

documentation in accordance with the 

conditions in each room. 

Seven characteristics of the respondents, 

almost half of respondents (42%) aged > 31-35 

years, all respondents (100%) were women, 

almost half of respondents (42%) work 

between 5-10 years old, most of the last 

education is D3 of Nursing, and all 

respondents (100%) is a permanent employee. 

It showed that the respondents to the category 

of productive age, work experience long 

enough at more than 5 years can be used as a 

benchmark of the validity and reliability of the 

instrument. The evaluation results of observation nursing 

diagnosis and interventions instrument used in the 

Teratai Room Amelia Pare Hospital were 

judged by the standards of nursing care was 

quite appropriate nursing diagnoses and 

nursing intervention instruments appropriate 

nursing interventions pretty standard. 

Recommendations from FGD about the 

structure of the nursing diagnosis and nursing 

interventions instrument based on standardized 

nursing language that was be applied at Teratai 

Room that participants agree with the 

arrangement of the instruments presented by 

researchers was the formulation of nursing 

diagnoses according NANDA International 

with selection check list according to the 

standard formulation of nursing diagnosis is 

composed of problem, etiology, symptomp for 

actual and problem diagnosis, etiology for the 

diagnosis of risk with check list format. 

Nursing intervention instruments used in 

accordance with the NOC (Nursing Outcomes 

Classification) and NIC (Nursing Intervention 

Classification) with a check list format. Results 

validity and reliability of the nursing diagnosis 

and interventions based standardized nursing 

language (NANDA-I, NOC, NIC) as follows: 



Jurnal Ners Vol 11 No 2 Oktober 2016: 157-163 

160 

 

 

Table 1. The validity of the nursing diagnoses  Instrument 

 

  

Table 1 shows that the validity of the 

Test results with SPSS to test Pearson's 

product moment correlation  by 7 respondents, 

with r table was 0.754. All the items about the 

nursing diagnosis instruments that tested by 

Pearson's product moment correlation with r 

count> r table so that the item is declared

Tabel 2. The validity of nursing interventions instrument 
No Intervensi 

keperawatan 

R hitung 

Uji korelasi pearson’s product 

moment  

R tabel 

(N=7) 

Kesimpulan 

1 Soal no 1 r : 0,959 0,754 Valid 

2 Soal no 2 r : 0,767 0,754 Valid 

3 Soal no 3 r : 0,959 0,754 Valid 

4 Soal no 4 r : 0,959 0,754 Valid 

 Rata-rata  

r hitung 

r : 0,911 0,754 Valid 

 

Tabel 3. The reliability of  nursing diagnoses and interventions instrument 
No Instrumen  Hasil 

Uji cronbach alpha  

R tabel 

(N=7) 

Kesimpulan 

1 Nursing diagnoses α : 0,862 0,754 Reliabel 

2 Nursing interventions α : 0,875 0,754 Reliabel 

 

Results and Analysis Research phase 2 

8 Characteristics of the respondents, the 

majority of nurses (50%) were aged 26-30 

years, mostly female (62%), the majority of 

nurses (50%) had a working time of 1-5 years, 

all respondents (100%) last education is D3 

nursing, and all respondents are permanent 

employees (100%). It shows that age is still 

relatively young, with the last D3 nursing 

education is expected to receive a new science 

properly so as to apply the instrument 

developed by researchers well. 

Characteristics of participants FGD 

stage 2 that almost half of the participants 

(33%) were aged> 40 years, the entire 

pastisipan (100%) were women, almost half of 

the participants (46%) working time> 15 years, 

most of the last education is D3 of Nursing, 

and the whole participants (100%) is a 

permanent employee. This shows that the FGD  

participants is included in the category of 

productive age, with long work experience.  

Socialization and training of the charging 

instrument-based nursing documentation Standardized 

Nursing Language (NANDA-I, NOC, NIC) in 

the RS Teratai Amelia Pare held on 13 April 

2016 in two phases with a total participant 47. 

Broadly speaking, the participants were able to 

accept material submitted by researchers. 

Training is conducted by nurses in hospitals 

Lotus Lounge Amelia's practice of charging 

instruments based nursing diagnosis and 

intervention Standardized Nursing Language 

(NANDA-I, NOC, NIC). The instrument has 

been developed for patients with a medical 

diagnosis of Diabetes Mellitus, so the nurse 

assigned to document nursing care in patients 

with Diabetes Mellitus. One nurse in charge of 

documenting a patient with Diabetes Mellitus 

in which the documentation is completed in a 

single shift. This process takes place from the 

date of 14 April-29 April, 2016 

The instrument has been developed for patients 

with a medical diagnosis of Diabetes Mellitus, 

so the nurse assigned to document nursing care 

No Nursing Diagnosis R hitung 

Uji corellationpearson’s product moment  

R table 

(N=7) 

Conclution 

1 Soal no 1 r : 0,767 0,754 Valid 

2 Soal no 2 r : 0,910 0,754 Valid 

3 Soal no 3 r : 0,910 0,754 Valid 

 Rata-rata r hitung r : 0,862 0,754 Valid 



Development of Nursing Diagnosis & Intervention Instrument (Diana Rachmania,dkk) 

161 

 

in patients with Diabetes Mellitus. One nurse 

in charge of The results of the evaluation of the 

ability of nurses in the application of nursing 

diagnoses and interventions instruments based 

on  Standardized Nursing Language (NANDA-

I, NOC, NIC) Show that the ability of 

respondents in filling nursing diagnosis 

instrument as a whole (100%) was good, the 

ability of respondents in filling nursing 

intervention instrument majority (75%) is 

good. The Evaluation of the ability of nurses in 

the application of nursing diagnoses and interventions 

instruments based on  Standardized Nursing 

Language (NANDA-I, NOC, NIC) at the 

Teratai Room shows that the ability of 

respondents in filling nursing intervention 

instrument majority (75%) is good. 

Recommendations FGD phase 2, is 

necessary to record a list of nursing diagnoses 

in patients with Diabetes Mellitus to assist in a 

language that has been standardized, the 

formulation of nursing interventions in 

accordance with the NOC and NIC, where the 

target score outcome can be modified with lists 

the normal standard of the best conditions of 

the patient and also for the interventions 

activity need to be made in full either act 

independently or collaborative actions, should 

be evaluated on a regular basis regarding the 

use of language standards of nursing and 

nursing interventions in accordance with the 

standards applicable at any given moment. 

Results of research findings to shape the 

development of the nursing diagnosis instrument 

based on the research that nursing diagnoses 

associated with causal factors for actual 

nursing diagnosis and risk factors for the 

nursing diagnosis risk in accordance languages 

NANDA-International, nursing diagnoses were 

made in accordance with the authority of 

nurses. 

Form of nursing interventions instrument that 

had been developed based on the research 

process, namely destinations care plan is only a 

target date for the achievement of goals and are 

the outcome of the desired target can be 

measured using a scale according to the NOC, 

the action plan drawn up to resolve the issue 

based on nursing diagnoses of patients, the 

action plan in the form of a sentence 

instruction, concise, easily understandable 

language firm with appropriate NIC. 

 

 

DISCUSSION 

Evaluation of The Implementation of 

Documentation Standards in Nursing Care 

in Teratai Room Amelia Hospital Pare 

Kediri 

The result evaluation of observation 

nursing diagnoses and interventions instrument 

that used in Teratai Room Amelia Hospital 

Pare were judged by the standards of nursing 

care based on Departement of Health standard. 

The result show that nursing diagnosis is quite 

appropriate standard because nursing diagnosis 

is still not linked to the causes of the gap and 

meet the needs of patients. Nursing diagnoses 

has been created by a nurse under the authority 

of nurses, nursing diagnosis actual still using 

one statement diagnoses, should have at least 2 

statements diagnoses to actual nursing 

diagnosis that is labeled as a problem and 

explain the factors related to the etiology. 

nursing interventions instrument quite match 

the standard because there are goals that are 

specific and measurable, but no time limit is 

realistic in the goals, action plan already exists 

but mixed into one coloumn between the plan 

and purpose of some nursing diagnoses so it is 

unclear boundary between the action plan one 

with an action plan on the other nursing 

diagnosis, plan of action in the form of 

sentences instructions, quick, firm with the 

language easily understandable. 

 

Development Nursing Diagnoses and Interventions 

Instrument Based on Standardized Nursing 

Language (NANDA-I, NOC, NIC). 

 

Recommendations from FGD about the 

structure of the nursing diagnosis and nursing 

interventions instrument based on standardized 

nursing language that will be applied at Teratai 

Room, that participants agree with the arrangement of the 

instruments presented by researchers is the formulation of 

nursing diagnoses according to the NANDA 

International with selection check list according to the 

standard formulation of nursing diagnosis is 

composed of problem, etiology, symptomp for 

actual and problem diagnosis, etiology for the 

diagnosis of risk with check list format. 

Nursing intervention instruments used in 

accordance with the NOC (Nursing Outcomes 

Classification) and NIC (Nursing Intervention 

Classification) with a check list format. 

The composition of the format used in 

the study of nursing diagnosis is composed of 



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162 

 

"nursing diagnoses" relates to "causes /related 

factors" is marked with "symptoms / defining 

characteristics". In the medical record has been 

based electronics, sometimes do not include 

the component "related factors" and 

"symptoms". However should need also to be 

noted that component in order to support the 

nursing diagnoses. Without such data it is 

impossible to verify the accuracy of the 

nursing diagnosis that affects the quality of 

nursing care (Herdman & Kamitsuru 2015). 

Planning is part of the organizing phase of the 

nursing process as a guide to direct the actions 

of nursing in an effort to help, relieve, solve 

problems or to meet the needs of clients 

(Setiadi 2012). 

Researchers develop nursing diagnoses 

and interventions instrument based on Standardized 

Nursing Language (NANDA-I, NOC, NIC) 

based on the results of FGD and based on the 

theory described in the preceding paragraph. 

The instrument has been designed by 

researchers presented and offered to the 

participants. In accordance with the expectations of the 

nurses who want their diagnosis and nursing 

intervention instrument which is simple, easy 

to use, according to the theory and efficient.  

 

Analysis of the validity and reliability 

Table 1 shows the test results of Pearson 

Product Moment Correlation average value of r 

count validity of the instrument diagnosis 0, 

862> 0.754, which means valid. Table 2 shows 

the Pearson Product Moment Correlation 

average value of r count validity intervention 

instruments 0, 911> 0.754, which means valid. 

Table 3 indicating the hasul IJI cronbach 

alphadengan count r diagnosis and interevsni 

instruments are 0.862 and 0.875> 0.754 

declared reliable. 

The principle of the preparation of the 

instrument according to Nusalam, (2013) that 

the validity and reliability. The principle is the 

validity of measurements and observations 

imply reliability principle instrument in 

collecting data. The instrument must be able to 

measure what should be measured. 

Good instrument instrument is tested for 

validity and reliability. Therefore, in the 

drafting process is very important to pay 

attention to the content of the instrument is 

able to measure what should be measured, and 

the results of these measurements are able to 

provide accurate information. A total of 7 

respondents employed researchers in 

measuring the validity and reliability of the 

instrument to deliver results that truly 

significant 

 

Dissemination and Training of The Development of 

Nursing Diagnoses and Interventions Instruments 

Based on  Standardized Nursing Language 

Dissemination and training of the development 

of nursing diagnoses and interventions instruments 

based on  Standardized Nursing Language 

(NANDA-I, NOC, NIC) in Amelia Hospital 

Pare went smoothly and was held on 13 April 

2016 attended by 47 participants in two stages. 

Training is preparation to improve the 

competence and skills of staff, promotion to 

leadership performance improvement (Danim 

2008) Indicators training methods can be 

viewed below (Hasibuan 2005) interest or 

interest on the method used; 2) harmonization 

of training activities with the sustainability of 

activities on the ground; 3) facilities adequate 

practice space; 4) The timeliness with trainees. 

Socialization activities carried out as 

many as two stages in order to facilitate nurses 

in Teratai Room, who was on duty in the 

morning shift. In ethics and responsibility, it is 

not possible to require all nurses to follow 

socialization Teratai Room  at a time where the 

nurse had to leave the patient who is being 

treated in the room. The existence of such 

training is expected to increase the knowledge 

of nurses about the standard language and its 

application. 

 

Evaluation of the ability and the opinion of nurses 

regarding application of nursing diagnoses and 

intervention based on  Standardized Nursing 

Language (NANDA-I, NOC, NIC) 

The ability of respondents in filling 

nursing diagnosis instrument as a whole 

(100%) was good, the ability of respondents in 

filling nursing intervention instrument majority 

(75%) is good. Evaluation should have clear 

objectives, in accordance with the objectives 

set in the program. (Potter, P 2011). 

Basically the development of nursing 

diagnoses and interventions instrument is not 

new for nurses. Every day nurses are faced 

with the activity. Therefore, it is possible in 

spite of the new information on how to fill out 

the instrument documentation with a new 

format, is not a difficult thing to be applied. In 



Development of Nursing Diagnosis & Intervention Instrument (Diana Rachmania,dkk) 

163 

 

reality the respondents were able to fill up 

easily and smoothly instruments developed. 

Recommendations  

Recommendations FGD phase 2, to the 

Amelia Hospital is necessary to record a list of 

nursing diagnoses in patients with Diabetes 

Mellitus to assist in the preparation of Stadar 

Nursing with a language that has been 

standardized, the formulation of nursing 

interventions in accordance with the NOC and 

NIC, where the target score outcome can be 

modified with lists the normal standard of the 

best conditions of the patient and also for the 

manufacture activity interventions need to be 

made in full either act independently or 

collaborative actions, should be evaluated on a 

regular basis regarding the use of language 

standards of nursing and nursing interventions 

in accordance with the standards applicable at 

any given moment. 

 

CONCLUSIONS & SUGGESTIONS 

Conclusions 

Recommendations outcomes of the 

Focus Group Discussion (FGD) in the 

development of instrument-based nursing 

documentation Standardized Nursing Language 

(NANDA-I, NOC, NIC) in the Lotus room 

Amelia Pare hospital in the form of a check list 

that nursing diagnosis instrument based on 

NANDA-International, intervention nursing by 

NOC and NIC.  Instruments of diagnosis and 

intervention, based nursing Standardized Nursing 

Language (NANDA-I, NOC, NIC) are valid and 

reliable. Training charging instrument-based nursing 

documentation Standardized Nursing Language 

(NANDA-I, NOC, NIC) in RS Amelia Pare went 

smoothly and was held on 13 April 2016 attended by 47 

participants in 2 stages. Application of instrument-based 

nursing diagnosis and intervention Standardized 

Nursing Language (NANDA-I, NOC, NIC) in 

the Lotus room Amelia Pare Hospital showed 

that the ability of the nurse in charge of 

nursing diagnosis instrument either wholly 

(100%), and nursing interventions most ( 75%) 

either. Recommendations outcomes of the 

Focus Group Discussion (FGD) on the 

instrument nursing documentation that nursing 

documentation standard evaluation instruments 

need to be observed on a regular basis and can 

be developed according to the policies in force 

at any given moment. 

 

Suggestion 

 

The nursing committee to begin record 

nursing diagnosis has ever appeared in any 

room so he could begin to formulate the 

nursing care based on the Standardized 

Nursing Language (NANDA-I, NOC, NIC) so 

as to produce formulation of nursing care in 

the form of check list and in accordance with 

the standards, as well as facilitate the nurse in 

the filling. For further research needs to be 

done research on the effectiveness of using the 

target score ourcome compared with normal 

data usage for the accuracy of data on nursing 

interventions made by the NOC 

 

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