This study aimed to determine the number and name of the diagnoses that often appear in COVID-19 patients in 2020-2022 at RIC-19, one of the private hospitals in Malang, as seen from medical records. The method used was a descriptive retrospective with a quantitative approach. This study used secondary data in the form of medical records of patients diagnosed with COVID-19 in private hospitals in Malang from March 2020 to March 2022. The results found that there were eight nursing diagnoses including hyperthermia, ineffective airway clearance, impaired gas exchange, acute pain, diarrhoea, risk of ineffective cerebral perfusion, nausea, and risk of nutritional deficits. The nursing diagnoses that often appear in COVID-19 patients in private hospitals in Malang are the same as the results of the study according to Hidayati et al. (2022) which states that the nursing diagnosis “cleansing ineffective airway” is the most dominant. However, these results do not include the signs and symptoms of minor and major patients in detail. The findings above illustrate that the documentation of nursing care by nurses is still not optimal, not structured assessment of initial nursing performed by the nurse on duty affects the implementation of nursing care. This can be an input for hospitals to continue to improve quality in documenting nursing care in the future.
Keywords: Standard Indonesian Nursing Diagnosis; COVID-19; Nursing care