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

Agarta, A., & Febriani, N. (2019). Kepuasan Perawat Mendokumentasikan Asuhan Keperawatan Dengan Metode Electromic Health Record Di Rumah Sakit. Jurnal Ilmiah Ilmu Keperawatan Indonesia, 9(2), 594–600.

Annisa, T. G. D., Maisharah, S., & Pratama, T. W. Y. (2022). Analisis Keberhasilan Penerapan Emr (Electronic Medical Record) Berdasarkan Metode Delone Dan Mclean Pada Unit Rawat Jalan Rumah Sakit Aisyiyah Bojonegoro. Indonesian Journal Of Health Information Management (Ijhim), 2(3), 1–5.

Bakhoum, N., Gerhart, C., Schremp, E., Jeffrey, A. D., Anders, S., France, D., & Ward, M. J. (2021). A Time And Motion Analysis Of Nursing Workload And Electronic Health Record Use In The Emergency Department. Journal Of Emergency Nursing, 47(5), 733–741. Https://Doi.Org/10.1016/J.Jen.2021.03.007

Damanik, B. N. (2023). Determinan Kelengkapan Berkas Rekam Medis Rawat Inap Di Rumah Sakit Umum Daerah Tanjungpura Kabupaten Langkat Tahun 2023. Jurnal Kesehatan Deli Sumatera, 1(2).

Delvita, D. (2023). Analisis Proses Implementasi Sistem Informasi Menuju Emr Di Rumah Sakit Citra Insani Palangka Raya. Diagnosa: Jurnal Ilmu Kesehatan Dan Keperawatan, 1(1), 10–15.

Dwijosusilo, K., & Sarni, S. (2018). Peranan Rekam Medis Elektronik Terhadap Sistim Informasi Manajemen Rumah Sakit Di Rumah Sakit Umum Haji Surabaya.

Fajariani, V. (2020). Analisis Kelengkapan Pengisian Dan Ketepatan Waktu Pengembalian Berkas Rekam Medis Pasien Rawat Inap Di Rsud Kota Makassar Tahun 2020 (Doctoral Dissertation, Universitas Hasanuddin).

Fore, A., Islim, F., & Shever, L. (2019). Data Collected By The Electronic Health Record Is Insufficient For Estimating Nursing Costs: An Observational Study On Acute Care Inpatient Nursing Units. International Journal Of Nursing Studies, 91, 101–107. Https://Doi.Org/10.1016/J.Ijnurstu.2018.11.004

Handayani, A. S. (2023). Implikasi Permenkes Nomor 24 Tahun 2022 Terhadap Pelaksanaan Rekam Medis Elektronik Melalui Sistim Informasi Puskesmas (Simpus)(Studi Kasus Di Puskesmas Temanggung) (Doctoral Dissertation, Universitas Katholik Soegijapranata Semarang).

Hani, U. R. M., Salim, N. A., & Wulandari, D. A. (2022). Evaluasi Pelaksanaan Elektronic Medical Record (Emr) Di Rawat Jalan Su Queen Latifa Yogyakarta. Infokes, 12(2), 7–12.

Hariyati, Rr. T. S., Yani, A., Eryando, T., Hasibuan, Z., & Milanti, A. (2016). The Effectiveness And Efficiency Of Nursing Care Documentation Using The Simpro Model. International Journal Of Nursing Knowledge, 27(3), 136–142. Https://Doi.Org/10.1111/2047-3095.12086

Hariyati, R. T. S., Hamid, A. Y., Eryando, T., & Hasibuan, Z. A. (2020). Usability And Satisfaction Of Using Electronic Nursing Documentation, Lesson-Learned From New System Implementation At A Hospital In Indonesia. International Journal Of Healthcare Management, 13(1), 45–52. Https://Doi.Org/10.1080/20479700.2018.1504387

Herlina, E. (2023). Dampak Penggunaan Rekam Medis Elektronik Terhadap Beban Kerja Perawat Di Rumah Sakit Prikasih. Journal Of Management Nursing, 2(4), 253–260. Https://Doi.Org/10.53801/Jmn.V2i4.13

Januraga, P. P., Wirawan, G. B. S., Harjana, N. P. A., & Ulandari, L. P. S. (2021). Rekam Kesehatan Elektronik: Kajian Model Dan Prototipe Sistem Informasi Kesehatan Untuk Industri 4.0. Bali, Indonesia. Baswara Press.

Janggeng, A., Sianturi, S. R., & Lina, R. N. (2022). Knowledge And Attitude Of Nurses With Computerized Based Nursing Care Documentation. Media Keperawatan Indonesia, 5(4), 267. Https://Doi.Org/10.26714/Mki.5.4.2022.267-273

Keding, Y. T., Adikara, F., & Wahyuni, W. (2022). Dokumentasi Rekam Medis Elektronik Dalam Waktu Tunggu Kepulangan Pasien: Structure Equation Model (Sem). Jurnal Health Sains, 3(2), 331–342. Https://Doi.Org/10.46799/Jhs.V3i2.430

Maha Wirajaya, M. K., & Made Umi Kartika Dewi, N. (2020). Analisis Kesiapan Rumah Sakit Dharma Kerti Tabanan Menerapkan Rekam Medis Elektronik. Jurnal Kesehatan Vokasional, 5(1), 1. Https://Doi.Org/10.22146/Jkesvo.53017

Maharani, E. M. (2023). Kesiapan Penerapan Rekam Medis Elektronik Dengan Metode Doq-It Rumah Sakit Al-Irsyad Surabaya (Doctoral Dissertation, Stikes Yayasan Rs Dr. Soetomo Surabaya).

Ramoo, V., Kamaruddin, A., Wan Nawawi, W. N. F., Chin Che, C., & Kavitha, R. (2022). Nurses’ Perception And Satisfaction Toward Electronic Medical Record System. Florence Nightingale Journal Of Nursing. Https://Doi.Org/10.5152/Fnjn.2022.22061

Wardani, I. G., Kurniati, T., & Sulaeman, S. (2022). Kompetensi Perawat, Sarana Prasarana Terhadap Dokumentasi Keperawatan Elektronik, Dampaknya Pada Patient Safety. Jurnal Keperawatan, 14(3), 567–574.