Pengembangan dokumentasi intervensi keperawatan OTEK berbasis EMR untuk peningkatan kinerja perawat: Tinjauan sistematis

Indrasari Wardani, Hanik Endang Nihayati, Ika Nur Pratiwi, Andi Safutra Suraya

Abstract


Pendahuluan: Penulisan intervensi keperawatan dalam dokumentasi asuhan keperawatan dianggap sangat memakan waktu, tidak ringkas, sehingga dokumentasi asuhan keperawatan yang ada ingin disesuaikan dengan standar asuhan keperawatan menurut PPNI. Dokumentasi asuhan keperawatan menurut standar merupakan salah satu bagian dari kinerja perawat. Penelitian ini bertujuan mendeskripsikan untuk memanfaatkan rekam medis elektronik (electronic medical record/EMR) untuk praktik klinis, penelitian, pendidikan dan surveilans.Metode: Tinjauan sistematis dilakukan pada penelitian ini menggunakan PRISMA. Database yang digunakan adalah Scopus, Science Direct, Proquest dan Pubmed. Pencarian artikel dari 2018-2022 dengan kata kunci "dokumentasi keperawatan" dan "rekam medis elektronik" dan "kinerja perawat". Tinjauan Sistematis ini menggunakan 20 artikel yang memenuhi kriteria inklusi. Hasil: Rekam medis elektronik (EMR) dapat memberikan kontribusi penting untuk meningkatkan kualitas layanan. Simpulan: Hasil tinjauan sistematis ini memberikan bukti bagi pembuat kebijakan untuk dapat mempertimbangkan pengembangan dokumentasi intervensi keperawatan OTEK berbasis EMR untuk peningkatan kinerja.


Keywords


Dokumentasi keperawatan; EMR; kinerja perawat; waktu kerja perawat

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References


Bail, K., Merrick, E., Bridge, C., & Redley, B. (2021). 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

Domingos, C. S., Boscaro, G. T., de Souza, C. C., Tannure, M. C., Chianca, T. C. M., & Salgado, P. de O. (2019). Adaptation of software with the nursing process for innovation units TT - Adaptação de software com o processo de enfermagem para unidades de internaçdo Adaptación de software con el proceso de enfermería para unidades de internación. Revista Brasileira de Enfermagem, 72(2), 400–407. https://doi.org/https://doi.org/10.1590/0034-7167-2018-0579

DPP PPNI, T. P. S. (2018). Standar Intervensi Keperawatan Indonesia Definisi dan Tindakan Keperawatan (Edisi 1 Ce). Persatuan Perawat Nasional Indonesia.

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, 1–12. https://doi.org/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, 1–12. https://doi.org/https://doi.org/10.1186/s12911-021-01405-0

Gil, M. F. H., Valcárcel, M. D. R., Llor, A. M. S., Ibáñez-López, F. J., Mikla, M., & López Montesinos, M. J. (2022). Validation of a Nursing Workload Measurement Scale, Based on the Classification of Nursing Interventions, for Adult Hospitalization Units. International Journal of Environmental

Research and Public Health, https://doi.org/https://doi.org/10.3390/ijerph192315528

(23), 15528.

Hossny, E. K. (2022). Studying nursing activities in inpatient units: a road to sustainability for hospitals.

BMC Nursing, 21, 1–11. https://doi.org/https://doi.org/10.1186/s12912-022-00926-x

Ilmiah, J., Batanghari, U., Syafrizal, R., & Putri, Z. M. (2021). Hubungan Kepuasan Kerja dengan Kinerja perawat di Rumah Sakit. 21(3), 1135–1138. https://doi.org/10.33087/jiubj.v21i3.1716

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/https://doi.org/10.1186/s12911-020-01244-5

Kilanska, D., Ogonowska, A., Librowska, B., Kusiak, M., Marczak, M., & Kozlowski, R. (2022). The Usability of IT Systems in Document Management, Using the Example of the ADPIECare Dorothea Documentation and Nurse Support System. International Journal of Environmental Research and Public Health, 19(14), 8805. https://doi.org/https://doi.org/10.3390/ijerph19148805

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/https://doi.org/10.3390/ijerph191710775

Maryam, R. S. (2015). Faktor-Faktor yang Berhubungan dental Kelengkapan Pendahuluan Metode. 18(1), 1–8.

Moen, H., Hakala, K., Peltonen, L.-M., Matinolli, H.-M., Suhonen, H., Terho, K., Danielsson-Ojala, R., Valta, M., Ginter, F., Salakoski, T., & Salanterä, S. (2020). Assisting nurses in care documentation: from automated sentence classification to coherent document structures with subject headings. Journal of Biomedical Semantics, 11, 1–12. https://doi.org/https://doi.org/10.1186/s13326-020- 00229-7

Napitu, J. (2020). Hubungan kinerja perawat dengan penerapan proses keperawatan di rumah sakit. https://doi.org/10.31219/osf.io/dfr9c

Oliveira, N. B. de, & Peres, H. H. C. (2021). Quality of the documentation of the Nursing process in clinical decision support systems. Revista Latino-Americana de Enfermagem, 29. https://doi.org/https://doi.org/10.1590/1518-8345.4510.3426

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, 1–7. https://doi.org/10.1155/2022/9352735

Perez-Martí, M. (2020). Electronic Records with Tablets at the Point of Care in an Internal Medicine Unit: OJNI. On - Line Journal of Nursing Informatics, 24(3).

Perez-Martí, M., Casado-Marin, L., & Guillen-Villar, A. (2022). Electronic Records With Tablets at the Point of Care in an Internal Medicine Unit: Before-After Time Motion Study. JMIR Human Factors, 9(1). https://doi.org/https://doi.org/10.2196/30512

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

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

Schenk, E., Schleyer, R., Jones, C. R., Fincham, S., Daratha, K. B., & Monsen, K. A. (2018). Impact of Adoption of a Comprehensive Electronic Health Record on Nursing Work and Caring Efficacy. CIN - Computers Informatics Nursing, 36(7), 331–338. https://doi.org/10.1097/CIN.0000000000000441

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

Steindal, S. A., Larsen, Marie HamNes, A. A. G., Heer, H. C., Lærum-Onsager, E., & Gjevjon, E. R. (2021). Technological literacy in nursing education: A scoping review. Journal of Professional Nursing, 37(2), 320–334. https://doi.org/https://doi.org/10.1016/j.profnurs.2021.01.008

Strudwick, G., Jeffs, L., Kemp, J., Sequeira, L., Lo, B., Shen, N., Paterson, P., Coombe, N., Yang, L., Ronald, K., Wang, W., Pagliaroli, S., Tajirian, T., Ling, S., & 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

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/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




DOI: http://dx.doi.org/10.30659/nurscope.9.1.60-70

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