Implementation of Standardized Nursing Language (SNL) in Nursing Documentation: A Scoping Review

Salsabila Fiqrotu Tsauroh; Ariani Arista Putri Pertiwi; Widyawati; Silvia Tri Wahyu Christaputri; Sihqina Ramadhani Selwis Raistanti

doi:10.30994/jnp.v9i4.1147

Authors

Salsabila Fiqrotu Tsauroh Master of Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Indonesia https://orcid.org/0009-0006-9971-8566
Ariani Arista Putri Pertiwi Department of Basic Nursing and Emergency, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Indonesia https://orcid.org/0000-0001-6439-2304
Widyawati Department of Pediatrics and Maternity Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Indonesia https://orcid.org/0000-0002-7923-1703
Silvia Tri Wahyu Christaputri Master of Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Indonesia https://orcid.org/0009-0001-1899-2728
Sihqina Ramadhani Selwis Raistanti Master of Nursing, Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Indonesia https://orcid.org/0009-0001-6826-9642

DOI:

https://doi.org/10.30994/jnp.v9i4.1147

Keywords:

Healthcare Facilities, Implementation, Nurses, Nursing Documentation, Standardized Nursing Language (SNL)

Abstract

Background: Nurses play a crucial role in improving the quality of care through standardized nursing practices. Standardized Nursing Language (SNL) provides as structured and systematic approach to articulating nursing care, facilitating accurate communication and promoting consistency in nursing documentation.

Purpose: This scoping review aimed to identify the implementation of SNL in nursing documentation.

Methods: A scoping review was conducted using four electronic databases: Garuda, PubMed, ScienceDirect, and Wiley. Eligible studies full text-original articles published in English or Indonesian between 2020 and August 2025 that examined SNL implementation in documentation within healthcare settings. Studies conducted in educational contexts, case reports, editorial commentaries, conference proceedings, and study protocols, were excluded.

Results: Across the 10 included studies, SNL implementation was associated with improvements nursing documentation quality. Five studies (50%) reported improved documentation accuracy and readability, while five (50%) reported more appropriate nursing diagnoses and interventions. The main implementation barriers were inadequate EHR support, limited nurses’ familiarity with SNL, and lack of standardized documentation formats, each reported in five studies (50%).

Conclusion: SNL implementation is associated with improved quality and consistency of nursing documentation. Further research using implementation science frameworks is warranted to systematically examine context specific barriers and facilitators of SNL implementation.

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References

Adubi, I. O., Olaogun, A. A., & Adejumo, P. O. (2018). Effect of standardized nursing language continuing education programme on nurses’ documentation of care at University College Hospital, Ibadan. Nursing Open, 5(1), 37–44. https://doi.org/10.1002/nop2.108.

Ameel, M., Leino, H., Kontio, R., van Achterberg, T., & Junttila, K. (2020). Using the Nursing Interventions Classification to identify nursing interventions in free-text nursing documentation in adult psychiatric outpatient care setting. Journal of Clinical Nursing, 29(17–18), 3435–3444. https://doi.org/10.1111/jocn.15382.

Anggariswa, A., Yuswardi, Y., Fikriyanti, F., Putra, A., & Mayasari, P. (2024). The Implementation of Nursing Diagnosis Based on Indonesian Nursing Diagnosis Standard: Retrospective Study. Galore International Journal of Health Sciences and Research, 9(2), 36–40. https://doi.org/10.52403/gijhsr.20240205.

Atashi, V., Movahedi Najafabadi, M., Afshari, A., & Ghafari, S. (2024). Barriers to effective clinical supervision from the perspective of nurses: A descriptive qualitative study. Nursing Open, 11(1), 1–10. https://doi.org/10.1002/nop2.2028.

Cho, I., Cho, J., Hong, J. H., Choe, W. S., & Shin, H. K. (2023). Utilizing standardized nursing terminologies in implementing an AI-powered fall-prevention tool to improve patient outcomes: a multihospital study. Journal of the American Medical Informatics Association : JAMIA, 30(11), 1826–1836. https://doi.org/10.1093/jamia/ocad145.

De Groot, K., De Veer, A. J. E., Paans, W., & Francke, A. L. (2020). Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences. International Journal of Nursing Studies, 104, 103523. https://doi.org/10.1016/j.ijnurstu.2020.103523.

Ebbers, T., Kool, R. B., Smeele, L. E., Dirven, R., den Besten, C. A., Karssemakers, L. H. E., Verhoeven, T., Herruer, J. M., van den Broek, G. B., & Takes, R. P. (2022). The Impact of Structured and Standardized Documentation on Documentation Quality; a Multicenter, Retrospective Study. Journal of Medical Systems, 46(7), 3–9. https://doi.org/10.1007/s10916-022-01837-9.

Emmanuel, C. E., Blessing, O. J., & Paulina, A. A.-I. (2024). Perception and Utilization of Standardized Nursing Languages among Nurses in south-south Nigeria. International Journal of Nursing and Midwifery, 16(1), 1–8. https://doi.org/10.5897/ijnm2023.0536.

Enebeli, E. C., Akpan-Idiok, P. A., & Chukwudozie, C. C. (2022). Nurses ’ lived experiences in the utilization of standardized nursing languages in documentation of nursing care , in Cross River State , Nigeria. International Journal of Nursing Knowledge, October, 1–8. https://doi.org/10.1111/2047-3095.12400.

Gelchu, M., Chala, G., & Tuke, G. (2025). Health professionals ’ readiness for and factors influencing electronic medical record systems implementation in Southern Oromia, Ethiopia, 2024 : a cross-sectional study. Frontiers in Digital Health, 7(April), 1–10. https://doi.org/10.3389/fdgth.2025.1531315.

Hendriana, Y., & Pranatha, A. (2020). Standar nursing language berbasis NANDA, NOC, dan NIC terhadap kualitas pengisian dokumentasi keperawatan. NURSCOPE: Jurnal Penelitian Dan Pemikiran Ilmiah Keperawatan, 5(2), 26. https://doi.org/10.30659/nurscope.5.2.26-31.

Herwawan, J. H., Tomasoa, V. Y., Jotlely, H., Termas, S., & Alfons, M. (2023). Analisis Pengetahuan Perawat Terkait Penggunaan 3s (Sdki, Slki, Siki) Dan Aplikatifnya Dalam Asuhan Keperawatan Joan. Jurnal Keperawatan, 16(1), 383–396.

Laukvik, L. B., Lyngstad, M., Rotegård, A. K., & Fossum, M. (2024). Utilizing nursing standards in electronic health records : A descriptive qualitative study. International Journal of Medical Informatics, 184(January). https://doi.org/10.1016/j.ijmedinf.2024.105350.

Mahfud, M., Hartono, H., Subijanto, A. A., & Anantanyu, S. (2025). Evaluating the Implementation of Indonesian Nursing Standards to Nurses ’ Performance in the Care Process Documentation for Inpatients. Advances in Social Science, Education and Humanities Research, ICoMSi 2024. https://doi.org/10.2991/978-2-38476-406-8.

Matthews, J., & Burgess, K. (2025). Assessing Positive Predictors for Implementation Success : Defining Organizational Readiness for Digital Transformation in Healthcare. Canadian Journal of Nursing Informatics, 20(2), 1–21.

Ojo, I. O., & Olaogun, A. A. (2023). Utilisation and Challenges of Standardised Nursing Languages in Nursing Process Booklets in Selected Tertiary Health Institutions in Nigeria. International Journal of Africa Nursing Sciences, 18(December 2022), 100552. https://doi.org/10.1016/j.ijans.2023.100552.

Peters, M. D. J., Marnie, C., Tricco, A. C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C. M., & Khalil, H. (2020). Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Synthesis, 18(10), 2119–2126. https://doi.org/10.11124/JBIES-20-00167.

Pranatha, A., & Nugraha, M. D. (2023). Pengaruh Penerapan Standard Nursing Language Berbasis Sdki, Slki, Siki Terhadap Kualitas Pengisian Dokumentasi Keperawatan Di Rumah Sakit Juanda Kuningan. Jurnal Ilmu Kesehatan Bhakti Husada: Health Sciences Journal, 14(01), 59–67. https://doi.org/10.34305/jikbh.v14i01.711.

Santos, C. Dos, Fabiana, D’Agostino, F., Härkönen, M., Nantschev, R., Christensen, B., Müller-Staub, M., & De Groot, K. (2024). Improving the quality of nursing care through standardized nursing languages: Call to action across European countries. International Journal of Medical Informatics, 192(September). https://doi.org/10.1016/j.ijmedinf.2024.105627.

Santos, F. C. Dos, D’Agostino, F., Harkonen, M., Nantschev, R., Christensen, B., Mulle-Staub, M., & Groot, K. De. (2024). Improving the quality of nursing care through standardized nursing languages: Call to action across European countries. Internasional Journal of Medical Informatics. https://doi.org/DOI: 10.1016/j.ijmedinf.2024.105627.

Sérgio, B. B., Santos, M. S., Carvalho, R. F. De, Luís, A., Pinto, C. B., & Maria, C. (2023). Clinical Supervision in Improving the Quality of Nursing Care: Empowerment of Medical-Surgical Hospitalization Teams. Nursing Forum, 2023. https://doi.org/10.1155/2023/5820168.

Somantri, I., Sekarwana, N., Mediawati, A. S., Ramoo, V., Yahaya, N. A., & Yudianto, K. (2021). Analysis of standardized nursing languages application in the context of nursing diagnosis in hospital in indonesia. Open Access Macedonian Journal of Medical Sciences, 9(T6), 173–178. https://doi.org/10.3889/oamjms.2021.7307.

Sulistyani, N., Rahayu, A. P., Sari, D. N., Rosiaty, L., Indryani, B., Muthmainah, Marissa, K., Juwiriah, Amalia, D. R., W, M. A. S., Anggara, C., & Dagu, F. (2024). Factors that Influence Nurses Competence in Implementing 3S Nursing Care (SDKI, SLKI, SIKI). Jurnal Kesehatan Pasak Bumi Kalimantan, 7(2), 224–232.

Sulistyawati, W., & Susmiati, S. (2020). The Implementation Of 3S (SDKI, SIKI, SLKI) to The Quality Of Nursing Care Documentation In Hospital’s Inpatient Rooms. STRADA Jurnal Ilmiah Kesehatan, 9(2), 1323–1328. https://doi.org/10.30994/sjik.v9i2.468.

Tauran, I., & Tunny, H. (2023). Penyusunan Standar Asuhan Keperawatan Dan Panduan AsuhanKeperawatan Sebagai Standar Penerapan Asuhan KeperawatanBerbasis SDKI, SLKI Dan SIKI Di Rumkit TK. IIProf. Dr. J.A. Latumeten Ambon. Jurnal Mahasiswa Ilmu Farmasi Dan Kesehatan, Vol.1(3), 249–256.

Wagner, C., Cummins, K., & Dean, M. (2025). Determining awareness of and readiness for standardized nursing languages in a mid-level midwestern hospital and associated school of nursing. International Journal of Nursing Knowledge, 36, 357–373. https://doi.org/DOI: 10.1111/2047-3095.12487.

Yanti, N. P. E. D., Sari, N. P. L. P., & Triana, I. K. D. L. (2019). Nursing Quality: Exploring Completeness and Accuracy Nursing Care Documentation At Hospital. Indonesian Journal of Global Health Research, 2(4), 4367–4380. https://doi.org/10.37287/ijghr.v2i4.250.

Yuwanto, M. A., Astutik, E. E., & Prasetyo, R. E. (2023). Application of nursing terminology based on the Indonesian nursing standards (diagnosis, outcome, and intervention) on the quality of filling out documentation. Jurnal Keperawatan, 14(02), 106–111. https://doi.org/10.22219/jk.v14i02.24106.

Zeffiro, V., Tempesta, S., Morandini, R., Alvaro, R., Vellone, E., Pucciarelli, G., & D’Agostino, F. (2025). Technologies to support nursing students in learning Standardized Nursing Languages: A systematic literature review. International Journal o Nursing Knowledge. https://doi.org/https://doi.org/10.1111/2047-3095.70001.

Zhai, Y., Yu, Z., Zhang, Q., Qin, W., Yang, C., & Zhang, Y. (2022). Transition to a new nursing information system embedded with clinical decision support: a mixed-method study using the HOT-fit framework. BMC Medical Informatics and Decision Making, 22(1), 1–20. https://doi.org/10.1186/s12911-022-02041-y.