Improving Documentation of Presenting Problems in The Emergency Department Using a Domain-Specific Ontology Base On 3S

Abstract

3S-based nursing documentation (SDKI, SLKI, and SLKI) has already been developed in Indonesia, but there is still little research related to the implementation of 3S documentation in emergency care. The use of specific documentation languages based on major and minor signs and symptoms facilitates diagnosis in emergency patients. Methods: The study aims to develop a 3S-based documentation format for the emergency room in the hospital. The research method used was the qualitative method of focus group discussion and study of medical records for the years 2020–2023. The survey was carried out in 3 hospitals in the rural district, involving 40 IGD nurses selected on the basis of inclusion criteria, i.e., they have been working at IGD for more than 5 years, have received 3S-based socialization and documentary training, and are ready to participate. Results: The results of the study revealed the twelve highest nursing problems emergency room corresponding to SDKI, there are inefficient breathing pattern, noneffective peripheral perfusion, decreased cardiac output, hypovolemia, hypervolemia, hyperthermia, acute pain, shock risk, risk of effective myocardial perfusion, risk of bleeding, and risk ineffective cerebral perfusion. Conclusions: The development of documentation at IGD uses a specialized ontological language in the application of artificial intelligence to facilitate decisionmaking from the results of the assessment to the intervention, external implementation, and evaluation of nursing diagnosis at IGD.