Pengembangan Dokumentasi Intervensi Keperawatan OTEK Berbasis EMR untuk Peningkatan Kinerja Perawat
Abstract
This study aims to describe to utilize electronic medical records (EMR) for clinical practice, research, education and surveillance. The research method uses systematic review was prepared based on Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA). This study used 8 articles that met the inclusion criteria. The results showed that literature search yielded 12,678 articles (337 from Scopus, 3,414 from Science Direct, 8,880 from Proquest and 47 from Pubmed). The research above explains that digitization in hospital nursing holds promise for changing the organization of care processes and, therefore, providing relief for nursing staff shortages. While advanced technology solutions and many application fields, comprehensive implementation remains challenging. Many publications show that electronic medical records (EMR) can make an important contribution to improving service quality. In conclusion, the results of this systematic review provide evidence for policy makers to be able to consider the development of EMR-based OTEK nursing intervention documentation for improving performance.
Keywords: Nursing documentation, EMR, Nurse Performance, Nurse working time.
References
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Albagmi, S. (2021). The Effectiveness of EMR Implementation Regarding Reducing Documentation Errors and Waiting Time for Patients in Outpatient Clinics: A Systematic Review. F1000Research, 10, 1–18. https://doi.org/10.12688/f1000research.45039.2
Bail, K., Merrick, E., Bridge, C., & Redley, B. (2020). Documenting Patient Risk and Nursing Interventions: Record Audit. Australian Journal of Advanced Nursing, 38(1), 36–44. https://doi.org/10.37464/2020.381.167
Farokhzadian, J., Khajouei, R., Hasman, A., & Ahmadian, L. (2020). Nurses Experiences and Viewpoints about the Benefits of Adopting Information Technology in Health Care: a Qualitative Study in Iran. BMC Medical Informatics and Decision Making, 20(1), 1–12. https://doi.org/10.1186/s12911-020-01260-5
Farzandipour, M., Mohamadian, H., Akbari, H., Safari, S., & Sharif, R. (2021). Designing a National Model for Assessment of Nursing Informatics Competency. BMC Medical Informatics and Decision Making, 21(1), 1–12. https://doi.org/10.1186/s12911-021-01405-0
Firmansyah, Y., & Widjaja, G. (2022). Pemberian Clinical Pathway dalam Pemberian Layanan Kesehatan dan Akibat Hukumnya. Jurnal Medika Hutama, 03(02), 1913–1946. Retrieved from https://journal.iaisambas.ac.id/index.php/Cross-Border/article/view/1103/880
Hossny, E. K. (2022). Studying Nursing Activities in Inpatient Units: a Road to Sustainability for Hospitals. BMC Nursing, 21, 1–11. https://doi.org/10.1186/s12912-022-00926-x
Jouparinejad, S., Foroughameri, G., Khajouei, R., & Farokhzadian, J. (2020). Improving the Informatics Competency of Critical Care Nurses: Results of an Interventional Study in the Southeast of Iran. BMC Medical Informatics and Decision Making, 20, 1–12. https://doi.org/10.1186/s12911-020-01244-5
Korte, L., & Bohnet-Joschko, S. (2022). Digitization in Everyday Nursing Care: A Vignette Study in German Hospitals. International Journal of Environmental Research and Public Health, 19(17), 10775. https://doi.org/10.3390/ijerph191710775
Meilina. (2021). Pengaruh Pengetahuan, Sikap dan Keterampilan Perawat terhadap Kepuasan Pasien. Jurnal Administrasi Bisnis, 11(1), 1–6. https://doi.org/https://doi.org/10.35797/jab.v11.i1.1-6
Nellisa, D., Rachmah, R., & Mahdarsari, M. (2022). Pendokumentasian Keperawatan di Ruang Rawat Inap Rumah Sakit. Jurnal Ilmiah Mahasiswa Fakultas Keperawatan, 1(4), 8–15. Retrieved from https://jim.usk.ac.id/FKep/article/view/23462
Pan, N., Luo, Y. Y., & Duan, Q. X. (2022). The Influence of PDCA Cycle Management Mode on the Enthusiasm, Efficiency, and Teamwork Ability of Nurses. BioMed Research International, 2022. https://doi.org/10.1155/2022/9352735
Saraswasta, I. W. G., Hariyati, R. T. S., & Fatmawati, U. (2020). Pelaksanaan Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap Rumah Sakit X Jakarta: Pilot Study. Dunia Keperawatan: Jurnal Keperawatan Dan Kesehatan, 8(2), 199. https://doi.org/10.20527/dk.v8i2.8024
Sarif, N. A., Mappamiring, & Malik Ihyani. (2020). Kinerja Pegawai dalam Penerapan Sistem Manajemen Kesehatan dan Keselamatan Kerja (SMK3) di PLN Rayon Panrita Lopi Bulukumba. Kajian Ilmiah Mahasiswa Administrasi Publik (KIMAP), 1(3), 1038–1054. Retrieved from https://journal.unismuh.ac.id/index.php/kimap/index
Sawondari, N., Alfiansyah, G., & Muflihatin, I. (2021). Analisis Kuantitatif Kelengkapan Pengisian Resume Medis di RUMKITAL dr. Ramelan Surabaya. J-REMI : Jurnal Rekam Medik Dan Informasi Kesehatan, 2(2 SE-), 211–220. https://doi.org/10.25047/j-remi.v2i2.2008
Shafiee, M., Shanbehzadeh, M., Nassari, Z., & Kazemi-Arpanahi, H. (2022). Development and Evaluation of an Electronic Nursing Documentation System. BMC Nursing, 21(1), 1–12. https://doi.org/10.1186/s12912-021-00790-1
Sobari, A., Nyorong, M., & Nuraini, N. (2022). Faktor yang Berhubungan dengan Catatan Keperawatan Dokumen Rekam Medis Rawat Inap di Rumah Sakit H. Adam Malik Medan. JUMANTIK (Jurnal Ilmiah Penelitian Kesehatan), 7(4), 395. https://doi.org/10.30829/jumantik.v7i4.12628
Strudwick, G., Jeffs, L., Kemp, J., Sequeira, L., Lo, B., Shen, N., … Jankowicz, D. (2022). Identifying and Adapting Interventions to Reduce Documentation Burden and Improve Nurses’ Efficiency in Using Electronic Health Record Systems (The IDEA Study): Protocol for a Mixed Methods Study. BMC Nursing, 21(1). https://doi.org/10.1186/s12912-022-00989-w
Suci, A. (2023). Analisis Keberhasilan Implementasi Rekam Medis Elektronik Dalam Meningkatkan Efisiensi Dan Mutu Pelayanan. Jurnal Kesehatan Dan Kedokteran, Vol. 2(2), 7–14. https://doi.org/10.56127/juk eke.v2i2.720
Tauran, I., & Tunny, H. (2023). Penyusunan Standar Asuhan Keperawatan dan Panduan Asuhan Keperawatan sebagai Standar Penerapan Asuhan Keperawatan Berbasis SDKI, SLKI dan SIKI Di Rumkit TK. II Prof. Dr. J.A. Latumeten Ambon. Jurnal Mahasiswa Ilmu Farmasi Dan Kesehatan, Vol.1(3), 249–256. https://doi.org/10.59841/jumkes.v1i3.193
Tsarfati, B., & Cojocaru, D. (2022). The Importance of Receiving Training in Computerized Technology for Nurses to Maintain Sustainability in the Health System. Sustainability, 14(23), 15958. https://doi.org/10.3390/su142315958
Wisuda, A. C., & Putri, D. O. (2020). Kinerja Perawat Pelaksana dalam Pendokumentasian Asuhan Keperawatan di Instalasi Rawat Inap. Jurnal ’Aisyiyah Medika, 4, 230–238. https://doi.org/10.36729/jam.v4i2.223
Published
2024-03-27
Section
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Copyright (c) 2024 Indrasari Wardani, Hanik Endang Nihayati, Ika Nur Pratiwi
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