Rekam Medis Elektronik Dalam Praktik Keperawatan Dan Pelayanan Kesehatan: Literatur Review
DOI:
https://doi.org/10.64931/jks.v5i2.182Keywords:
EMR, EHR, Dokumentasi Keperawatan, Rekam Medis Elektronik, Akurasi, EfisiensiAbstract
Digitalisasi layanan kesehatan melalui rekam medis elektronik merupakan strategi global untuk meningkatkan mutu dokumentasi keperawatan serta mendukung pengambilan keputusan klinis berbasis data. Mengevaluasi dampak implementasi rekam medis elektronik terhadap akurasi dokumentasi, integritas data, efisiensi layanan, dan sikap tenaga kesehatan. Tinjauan literatur terhadap artikel dari Scopus dan Sage (2020–2025) dengan kata kunci terkait rekam medis elektronik. Dari 1.374 artikel yang teridentifikasi, enam studi memenuhi kriteria inklusi dan dianalisis. Rekam medis elektronik meningkatkan akurasi diagnosis keperawatan, kelengkapan dokumentasi, dan efisiensi manajemen kasus. Tantangan tetap ada berupa kesalahan dokumentasi, keterbatasan pemanfaatan data rutin, serta kurangnya standardisasi terminologi. Sikap positif tenaga kesehatan terhadap rekam medis elektronik memerlukan dukungan organisasi, anggaran, dan infrastruktur teknologi. Keberhasilan implementasi rekam medis elektronik bergantung pada integrasi teknologi dengan kesiapan sumber daya manusia, kebijakan organisasi, dan kerangka manajemen data yang komprehensif. Temuan ini memberikan implikasi bagi kebijakan kesehatan dan pendidikan keperawatan untuk memastikan mutu dokumentasi, integritas data, serta efektivitas pengambilan keputusan berbasis bukti
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