Description and validation of nursing diagnosis using electronic documentation: Study cases in mother and child hospital Indonesia

Background: A nursing diagnosis is a clinical judgment concerning a human response to a health condition, vulnerability for that response, by an individual, family, group, or community. For the determination of the right nursing diagnosis, a system that guides nurses in implementing care professionally is needed. Objective: To describe the nursing diagnosis in mother and child cases validated by using a management nursing information system. Methods: This case study used secondary data from 5.294 medical records. Medical records were retrieved from the server, analyzed, and validated by using the mapping model in accordance with the most frequent cases in mothers and children in the hospital. Approximately ten million (10.021) nursing diagnoses were performed by nurses and validated by using a mapping model of medical cases and nursing assessment. The selected medical cases were the five most frequent cases, namely normal delivery, cesarean delivery, healthy newborn, fever, and dengue in children. Results: This study yielded the five most frequent nursing diagnoses, namely risk for infection (20.1%), pain (13.37%), anxiety (9.37%), the risk for imbalanced fluid volume (9.36%), and risk for bleeding (9.27%). Conclusion: The electronic nursing documentation could help to determine a nursing diagnosis and had been validated for its appropriateness with assessment and the most common cases in mothers and children. Information and system training development are required to carry out the nursing process comprehensively.