Faktor Human, Organisasi dan Teknologi terhadap Kelengkapan Pengisian Dokumentasi Asuhan Keperawatan Melalui Rekam Medis Elektronik
Abstract
This study aims to determine the influence of human, organizational, and technological factors on the completeness of nursing care documentation through Electronic Medical Records (EMR) at RSUD Waru Pamekasan. The method used is observational with a cross-sectional approach. The population consists of all nursing staff at RSUD Waru Pamekasan, totaling 108 individuals, and a sample of 108 individuals was obtained using total sampling techniques. The measurement tool employed is a questionnaire, and the data analysis used is ordinal regression testing. The results show that human and technological factors have significant values; specifically, the human factor has a p-value of 0.001 with an Odds Ratio (OR) of 1.022, while the technological factor has a p-value of 0.000 with an OR of 1.065. This indicates that the technological factor has a greater influence than the human factor on the completeness of nursing care documentation through electronic medical records at RSUD Waru Pamekasan. In conclusion, the technological factor has a more significant impact compared to the human factor on the completeness of nursing care documentation through electronic medical records. This suggests that the quality and ease of use of technology are more crucial to the success of documentation than the skills or behaviors of nurses.
Keywords: Completeness of nursing care, Organization, Electronic Medical Records, Technology, Human.
References
Arsana, S. M. D. B., Suardhika, I. N., & Rismawan, P. A. E. (2023). Pengaruh Gaya Kepemimpinan, Kemampuan Kerja dan Imbalan terhadap Kinerja Perawat pada Rumah Sakit Jiwa Provinsi Bali. EMAS, 4(5), 1304-1322. https://e-journal.unmas.ac.id/index.php/emas/article/view/6676
Astuti, N. (2022). Komunikasi SBAR dalam Pelayanan Keperawatan. Penerbit NEM.
Damanik, M., Fahmy, R., & Merdawati, L. (2020). Gambaran Keakuratan Dokumentasi Asuhan Keperawatan. Jurnal Kesehatan Andalas, 8(4). http://dx.doi.org/10.25077/jka.v8i4.1131
Hidayat, A. A. (2021). Dokumentasi Keperawatan; Aplikasi Praktik Klinik. Health Books Publishing.
Irianto, G., Dedi, B., & Rohayani, L. (2024). Faktor–faktor yang Mempengaruhi Kepatuhan Perawat dalam Pendokumentasian Asuhan Keperawatan pada Elektronik Rekam Medis di Rsud Pameungpeuk Garut. Indonesian Nursing Journal of Education and Clinic, 4(1), 70-87. https://ejournal.penerbitjurnal.com/index.php/health/article/view/709
Manurung, M. E. M., Sianipar, C. M., & Silalahi, V. (2023). Analisis Faktor-faktor yang Mempengaruhi Perilaku Perawat dalam Pendokumentasian Keperawatan di RSU Daerah Porsea. Jurnal Keperawatan Cikini, 4(1), 15-23. https://jurnal.akperrscikini.ac.id/index.php/JKC/article/view/101
Marsen, A. R. (2024). Pengaruh Tingkat Pengetahuan dan Sikap Perawat terhadap Kelengkapan Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap Rumah Sakit Umum Kaliwates Jember (Doctoral dissertation, Politeknik Negeri Jember). https://sipora.polije.ac.id/32824/
Mukharram, M. F., Nurita, D. P., & Paramarta, V. (2024). Penerapan Rekam Medis Elektronik di Rumah Sakit. Journal of Social and Economics Research, 6(1), 966-973. https://doi.org/10.54783/jser.v6i1.471
Nursalam, N. (2020) ‘Metodologi Penelitian Ilmu Keperawatan - Ners Unair Repository’, 2020.
Orangbio, T., Wagey, F. W., & Doda, D. V. D. (2023). Faktor-faktor yang Memengaruhi Analisis Kelengkapan Pengisian Rekam Medis Elektronik Instalasi Rawat Jalan Rsup Prof Dr. Rd Kandou Manado. Jurnal Kesehatan Tambusai, 4(2), 1210-1223. https://doi.org/10.31004/jkt.v4i2.15438
Rosita, R., Rizky, A. P. K., & Afifah, N. N. (2021, June). Faktor Penyebab Ketidaklengkapan Dokumen Rekam Medis Rawat Inap pada Kasus Single Live Birth. In Prosiding Seminar Informasi Kesehatan Nasional (pp. 391-399). https://doi.org/10.47701/sikenas.v0i0.1277
Seniwati, S., Anugrahwati, R., Silitonga, J. M., Hutagaol, R., Gunawan, D., Sihura, S. S. G., ... & Solehudin, S. (2022). Buku Manajemen Keperawatan.
Seniwati, S., Sudarno, S., & Fatmasari, R. (2022). Pengaruh Kepemimpinan, Iklim Organisasi, Motivasi, dan Kepuasan Kerja terhadap Kinerja Guru Sekolah Dasar Gugus IV Tampan Pekanbaru. Aksara: Jurnal Ilmu Pendidikan Nonformal, 8(1), 31-42. http://dx.doi.org/10.37905/aksara.8.1.31-42.2022
Suhartini, T., Washilah, W., & Hadi, W. N. (2023). Pendokumentasian Asuhan Keperawatan Berbasis Standar Diagnosis Keperawatan Indonesia Bagi Motivasi, Beban Kerja, Supervisi, Model Kepemimpinan dan Organisasi, Serta Fasilitas Layanan. Journal of Telenursing (JOTING), 5(1), 1316-1326. https://doi.org/10.31539/joting.v5i1.5090
Suwignjo, P., Maidartati, M., Asmara, L. N., Saputra, A., & Khasanah, U. (2022). Gambaran Kelengkapan Dokumentasi Asuhan Keperawatan di Instalasi Rawat Inap Rsud Kota Bandung. Jurnal Keperawatan BSI, 10(2), 226-233. https://ejurnal.ars.ac.id/index.php/keperawatan/article/view/893
Umar, N. E., Meri, N. D., Kep, M., Fithriyani, N., Kep, M., Zakiyah, A., ... & Putri, E. M. I. (2024). Buku Ajar Manajemen Keperawatan. Mahakarya Citra Utama Group.
Wahyuningsih, A. D., Muharni, S., & Wardhani, U. C. (2024). Hubungan Beban Kerja dengan Kelengkapan Dokumentasi Asuhan Keperawatan Ruang Rawat Inap Rumah Sakit Bakti Timah Karimun Tahun 2023. Protein: Jurnal Ilmu Keperawatan dan Kebidanan., 2(2), 57-70. https://doi.org/10.61132/protein.v2i2.201
Washilah, W., & Suhartini, T. (2023). Analisis Faktor dalam Menilai Kualitas Dokumentasi Keperawatan. Media Husada Journal Of Nursing Science, 4(1), 36-42. https://doi.org/10.33475/mhjns.v4i1.120
Zahrani, P. S. (2023). Analisis Karakteristik Individu dan Pekerjaan terhadap Kinerja Tenaga Kesehatan dalam Kelengkapan Rekam Medis di Rumah Sakit Laras Kabupaten Simalungun. Jurnal Inovasi Kesehatan Masyarakat, 4(1), 19-32. http://ejournal.delihusada.ac.id/index.php/JIKM/article/view/1261
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