1. Home
  2. Vol 10, No 2 (2024)
  3. Aprilia

Implementasi Rekam Medis Elektronik di Kalangan Perawat Rumah Sakit: A Scoping Review

DOI: 10.29241/jmk.v10i2.1918

Author

Dini Aprilia(1),
(1) Universitas Padjadjaran,Indonesia
Corresponding Author

Full Text

Full Text: View / Download PDF

Article Metrics

Abstract View : 5 times; PDF Download : 2 times

Abstract

Rekam medis elektronik (Electronic Health Records, EHR) kian populer di rumah sakit untuk meningkatkan komunikasi, perawatan pasien, serta mengurangi kesalahan administrasi, tetapi transisi dari sistem berbasis kertas ke EHR memunculkan isu kerahasiaan, performa sistem, dan beban kerja perawat. Tujuan dari tinjauan ini adalah untuk mengevaluasi bagaimana perawat rumah sakit mengimplementasikan EHR. Menggunakan paradigma Arskey dan O'Malley, tinjauan skop ini mencari data dari dua basis data, yaitu CINAHL Plus dengan Full Text, Academic Search Complete, dan Scopus dengan kata kunci tertentu, memfokuskan pada publikasi berbahasa Inggris dari tahun 2013 hingga 2023. Dari pencarian tersebut, ditemukan delapan artikel yang mengidentifikasi enam tema utama terkait implementasi EHR, termasuk desain dan evaluasi konten EHR, waktu yang dihabiskan perawat dalam mengerjakan EHR, persepsi perawat terhadap penggunaan EHR, faktor yang mempengaruhi beban kerja mental perawat, diagnosis keperawatan berbasis EHR, serta hubungan EHR dengan mortalitas pasien. Kesimpulannya, implementasi EHR dalam keperawatan mencakup pengembangan sistem EHR dan penggunaan layanan kesehatan yang berkualitas, dengan melibatkan perawat dalam setiap aspek evaluasi dan pengadaannya untuk mengoptimalkan penggunaan EHR yang berdampak pada Management Patient Safety dan kualitas pendokumentasian.

Keywords

Electronic Health Records, EHR, Hospital, Nurses

References

Akhu-Zaheya, L., Al-Maaitah, R., & Bany Hani, S. (2018). Quality of nursing documentation: Paper-based health records versus electronic-based health records. Journal of Clinical Nursing, 27(3-4), e578-e589.

Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19–32. https://doi.org/10.1080/1364557032000119616

Aromataris, E., & Munn, Z. (Eds.). (2020). JBI reviewers manual. https://doi.org/10.46658/JBIRM-19-01

Baumann, L. A., Baker, J., & Elshaug, A. G. (2018). The impact of electronic health record systems on clinical documentation times: A systematic review. Health Policy, 122(8), 827-836. https://doi.org/10.1016/j.healthpol.2018.05.014

Bowles, K. H., Dykes, P., & Demiris, G. (2015). The use of health information technology to improve care and outcomes for older adults. Research in Gerontological Nursing, 8(1), 5-10.

Chung, S.-C., Gedeborg, R., Nicholas, O., James, S., Jeppsson, A., Wolfe, C., Heuschmann, P., Wallentin, L., Deanfield, J., & Timmis, A. (2014). Acute myocardial infarction: A comparison of short-term survival in national outcome registries in Sweden and the UK. The Lancet, 383(9925), 1305-1312.

Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients' mortality. American Journal of Critical Care, 22(4), 306-313. https://doi.org/10.4037/ajcc2013426

Collins, S. A., & Vawdrey, D. K. (2012). "Reading between the lines" of flow sheet data: Nurses' optional documentation associated with cardiac arrest outcomes. Applied Nursing Research, 25(4), 251-257.

Denaxas, S. C., & Morley, K. I. (2015). Big biomedical data and cardiovascular disease research: Opportunities and challenges. European Heart Journal - Quality of Care and Clinical Outcomes, 1(1), 9-16.

Hariyati, R. 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.

Hariyati, Rr. T. S., Handiyani, H., Rahman, L. A., & Afriani, T. (2020). Description and validation of nursing diagnosis using electronic documentation: Study cases in Mother and Child Hospital Indonesia. The Open Nursing Journal, 14(1), 300-308. https://doi.org/10.2174/1874434602014010300

Harmon, C., Fogle, M., & Roussel, L. (2015). Then and now: Nurses' perceptions of the electronic health record. On-Line Journal of Nursing Informatics, 19(1).

Hlatky, M. A., Ray, R. M., Burwen, D. R., Margolis, K. L., Johnson, K. C., Kucharska-Newton, A., Manson, J. E., Robinson, J. G., Safford, M. M., & Allison, M. (2014). Use of Medicare data to identify coronary heart disease outcomes in the Women's Health Initiative. Circulation: Cardiovascular Quality and Outcomes, 7(1), 157-162.

Huber, M. T., Highland, J. D., Krishnamoorthi, V. R., & Tang, J. W.-Y. (2018). Utilizing the electronic health record to improve advance care planning: A systematic review. American Journal of Hospice and Palliative Medicine, 35(3), 532-541. https://doi.org/10.1177/1049909117715217

Hsiao, J.-L., & Chen, R.-F. (2015). Critical factors influencing physicians' intention to use computerized clinical practice guidelines: An integrative model of activity theory and the technology acceptance model. BMC Medical Informatics and Decision Making, 16(1), 1-15.

Javier Aguirre, J., Yong Yu, J., Jung, K.-H., et al. (2023). Computationally efficient and stable real-world synthetic emergency room EHR data generation: High similarity and privacy preserving diffusion model approach. Research Square (Preprint), 10 December 2023, Version 1. https://doi.org/10.21203/rs.3.rs-3653078/v1

Karp, E. L., Freeman, R., Simpson, K. N., & Simpson, A. N. (2019). Changes in efficiency and quality of nursing electronic health record documentation after implementation of an admission patient history essential data set. CIN: Computers, Informatics, Nursing, 37(5), 260-265. https://doi.org/10.1097/CIN.0000000000000516

Khan, A. R., Rosenthal, C. D., Ternes, K., Sing, R. F., & Sachdev, G. (2022). Time spent by intensive care unit nurses on the electronic health record. Critical Care Nurse, 42(5), 44-50.

Krumholz, H. M., Normand, S.-L. T., & Wang, Y. (2014). Trends in hospitalizations and outcomes for acute cardiovascular disease and stroke, 1999-2011. Circulation, 130(12), 966-975.

Kutney-Lee, A., Sloane, D. M., Bowles, K. H., Burns, L. R., & Aiken, L. H. (2019). Electronic health record adoption and nurse reports of usability and quality of care: The role of work environment. Applied Clinical Informatics, 10(1), 129-139. https://doi.org/10.1055/s-0039-1678551

Love, B. A., Ayamolowo, O. O., & Irinoye, A. S. (2023). Utilization of electronic health records and associated factors among nurses in a faith-based teaching hospital, Ilishan, Nigeria. JAMIA Open. https://doi.org/10.1093/jamiaopen/ooad059

McCrorie, C., Benn, J., Johnson, O., et al. (2019). Staff expectations for the implementation of an electronic health record system: A qualitative study using normalisation process theory. BMC Medical Informatics and Decision Making, 19, 222. https://doi.org/10.1186/s12911-019-0952-3

Shafiee, M., Shanbehzadeh, M., Nassari, Z., & Kazemi-Arpanahi, H. (2022). Development and evaluation of an electronic nursing documentation system. BMC Nursing, 21(1), 15. https://doi.org/10.1186/s12912-021-00790-1

Shan, Y., Shang, J., Yan, Y., & Ye, X. (2023). Workflow interruption and nurses' mental workload in electronic health record tasks: An observational study. BMC Nursing, 22(1), 63. https://doi.org/10.1186/s12912-023-01209-9

Stephanie, C. G. (2015). Technology-enabled services for older people living at home independently: Lessons for public long-term care authorities in the EU Member States.

Strudwick, G., McGillis Hall, L., Nagle, L., & Trbovich, P. (2018). Acute care nurses' perceptions of electronic health record use: A mixed method study. Nursing Open, 5(4), 491-500. https://doi.org/10.1002/nop2.157

Sutton, D. E., Fogel, J. R., Giard, A. S., Gulker, L. A., Ivory, C. H., & Rosa, A. M. (2020). Defining an essential clinical dataset for admission patient history to reduce nursing documentation burden. Applied Clinical Informatics, 11(3), 464-473.

Wang, J. Y., Ho, H. Y., Chen, J. D., et al. (2015). Attitudes toward inter-hospital electronic patient record exchange: Discrepancies among physicians, medical record staff, and patients. BMC Health Services Research, 15, 264. https://doi.org/10.1186/s12913-015-0896-y

Walker, R. M., Burmeister, E., Jeffrey, C., Birgan, S., Garrahy, E., Andrews, J., Hada, A., & Aitken, L. M. (2020). The impact of an integrated electronic health record on nurse time at the bedside: A pre-post continuous time and motion study. Collegian, 27(1), 63-74. https://doi.org/10.1016/j.colegn.2019.06.006

Westra, B. L., Latimer, G. E., Matney, S. A., Park, J. I., Sensmeier, J., Simpson, R. L., Swanson, M. J., Warren, J. J., & Delaney, C. W. (2015). A national action plan for sharable and comparable nursing data to support practice and translational research for transforming health care. Journal of the American Medical Informatics Association, 22(3), 600-60

Refbacks

  • There are currently no refbacks.




Copyright (c) 2024 Dini Aprilia

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.