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

DOI: 10.29241/jmk.v10i2.1918

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Dini Aprilia(1*)

(1) Universitas Padjadjaran,Indonesia
(1*) Corresponding Author

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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

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