Evaluasi Penerapan Electronic Medical Record oleh Perawat Dalam Pendokumentasian Asuhan Keperawatan dan Dampaknya Terhadap Kepuasan Perawat: A Literature Review

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ABSTRACT

Current technology trends are undergoing development in the 4th Industrial Revolution, which also has an impact on progress in the field of healthcare, especially in the application of digitalization information technology in hospitals to electronic nursing documentation.  To determine the overview of the evaluation of the implementation of electronic medical records in nursing documentation performed by nurses. The research used a literature review approach conducted through three electronic sources such as clinicalkey nursing, google scholar, Taylor&Francis and Wiley Journal of Finance. Article selection was based on inclusion criteria that included title relevance with keywords electronic medical record/rekam medis elektronik, nursing documentation/dokumentasi keperawatan/nursing care documentation, nurse satisfaction/kepuasan perawat, English, Indonesian, full text. The results of the literature review on the 14 journals provide an overview of the evaluation that the use of electronic medical records, especially in nursing documentation, has a positive impact on patient safety and the quality of nursing care if it meets the requirements such as human resource readiness, facilities and infrastructure, and nursing documentation module design. It is important for institutions to overcome challenges in implementing Electronic Medical Record (EMR), including changes in work procedures, training for human resources who will use this system, data protection, and resistance to cultural transformation within the organization.

Keywords: Electronic Medical Records, Nursing Documentation, Nurse Satisfaction

ABSTRAK

Tren teknologi saat ini sedang mengalami perkembangan dalam Revolusi Industri 4.0 yang juga memiliki pengaruh pada kemajuan di bidang kesehatan, terutama dalam penerapan teknologi informasi digitalisasi di rumah sakit terhadap dokumentasi keperawatan elektronik. Untuk mengetahui gambaran evaluasi penerapan rekam medik elektronik dalam pendokumentasian asuhan keperawatan yang dilakukan oleh perawat. Penelitian menggunakan pendekatan tinjauan literatur yang dilakukan melalui tiga sumber elektronik seperti clinicalkey nursing, google scholar, Taylor&Francis dan Wiley Journal of Finance. Seleksi artikel didasarkan pada kriteria inklusi yang mencakup relevansi judul dengan kata kunci rekam medis elektronik/electronic medical record, dokumentasi keperawatan/nursing documentation/nursing care documentation, kepuasan perawat/nurse satisfaction, berbahasa inggris, berbahasa Indonesia, full text. Hasil tinjauan literatur pada 14 jurnal tersebut memberikan gambaran evaluasi bahwa penggunaan rekam medis elektronik terutama dalam pendokumentasian asuhan keperawatan memiliki dampak positif pada keselamatan pasien dan mutu asuhan keperawatan apabila memenuhi syarat seperti kesiapan SDM, sarana prasarana, rancangan modul dokumentasi keperawatan. Penting bagi instansi untuk mengatasi tantangan dalam pelaksanaan Electronic Medical Record (EMR), termasuk perubahan dalam tata cara kerja, pelatihan bagi SDM yang akan menggunakan sistem ini , perlindungan data, serta resistensi terhadap transformasi budaya di dalam organisasi.

Kata Kunci: Electronic Medical Records, Dokumentasi Keperawatan, Kepuasan Perawat