Factors Associated with Incomplete Electronic Medical Records by Nurses after the Transition from Manual Documentation

Hesti Puspita Dewi; Maryana Maryana; Hermain Hermain

Authors

Hesti Puspita Dewi Institut Citra Internasional
Maryana Maryana Institut Citra Internasional
Hermain Hermain Institut Citra Internasional

Keywords:

attitude, electronic medical records, hospital, motivation, workload

Abstract

Introduction: Electronic medical records are a crucial part of healthcare. Nursing staff have a crucial responsibility to document all nursing actions or care provided to patients. Incomplete medical records can impact the quality of care and patient safety.

Objective: The purpose of this study was to determine factors associated with incomplete electronic medical records by nurses following the transition from manual documentation.

Method: This type of research was conducted with a cross-sectional design through a quantitative method approach. The population in this study were all nurses in the inpatient ward at Dr. (H.C) Ir. Soekarno Regional General Hospital in 2025 with a total of 160 nurses and a sample of 125 people. The sampling technique used in this study was the Non-Probability Sampling Technique with the Quota Sampling method. Data analysis used univariate analysis and bivariate analysis with the chi-square test with a 95% confidence level (α = 0.05).

Result: This study shows that there is a relationship between workload (p = 0.033, POR = 2.526), motivation (p = 0.003 and POR = 5.238) and attitude (p = 0.004, POR = 3.441) with incomplete electronic medical records by nurses after the transition to manual documentation. In the variables of age (p = 0.210) and length of service (p = 0.127) it was concluded that there was no relationship with incomplete electronic medical records by nurses after the transition to manual documentation.

Conclusion: The suggestion from this study is the importance of maintaining and improving nurse motivation, maintaining nurse attitudes, regulating the distribution of nurse workload in inpatient rooms and conducting a refresher regarding the use of electronic medical records in the hospital environment.

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References

Adiputra, I Made Sudarma, dkk. (2021). Metodologi penelitian kesehatan Medan: Yayasan Kita Menulis.

Akhu‐Zaheya, L., Al‐Maaitah, R., & Bany Hani, S. (2021). Quality of Nursing Documentation: Paper‐Based Health Records Versus Electronic‐Based Health Records. Journal Of Clinical Nursing, 27(3–4). https://doi.org/10.1111/Jocn.14097

Amalia, Hema Malini, S. Y. (2022). Kepuasan Perawat Terhadap Kualitas Pendokumentasian Asuhan Keperawatan Berbasis Komputer. Jurnal Keperawatan Indonesia, https://doi.org/10.7454/jki.v21i3.680

Amalia, & Herawati, (2018). Faktor-Faktor Kelengkapan Pendokumentasian Asuhan Keperawatan Di Instalasi Rawat Inap Rsud Lubuk Sikaping. Prosiding Seminar Kesehatan Perintis E, 1(1), 2622–2256.

Andriana, S., & Anggraini, R. B. (2024). Evaluasi Pendokumentasian 3S (SDKI, SIKI, SLKI) Dalam Sistem Informasi Manajemen Rumah Sakit Di Ruang Rawat Dewasa Kelas III RSUD Dr (Hc) Ir. Soekarno Provinsi Kepulauan Bangka Belitung Tahun 2024. Jurnal Kesehatan Tambusai, 5(3), 9785-9798.

Anila, A., Kusumajaya, H., & Maryana, M. (2023). Faktor-faktor yang Berhubungan dengan Ketidaklengkapan Dokumentasi Asuhan Keperawatan di Ruang Rawat Inap. Jurnal Penelitian Perawat Profesional, 5(2), 627–636. https://doi.org/10.37287/jppp.v5i2.1531

Ardiansyah, (2022). Penggunaan Rekam Medik Elektronik dalam Keperawatan, Kemenkes https://yankes.kemkes.go.id/view_artikel/507/penggunaan-rekam-medik-elektronik-dalam-keperawatanDirektorat Jenderal Pelayanan Kesehatan. Published online 2022 Jul 26. Diakses pada 13 Januari 2025P.

Arizal, Ichsan Budiharto, A. N. (2019). Analisis Rencana Penerapan Sistem Informasi Dalam Pendokumentasian Asuhan Keperawatan Di Rumah Sakit Universitas Tanjungpura. Jurnal Ilmu-Ilmu Kesehatan.

Basri, Burhanuddin dkk (2020). konsep dokumentasi keperawatan. Bandung:Media Sains Indonesia

Baumann, L. A., Baker, J., & Elshaug, A. G. (2021). 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

Gunawan, G. (2019). Faktor-Faktor Yang Memengaruhi Penerimaan Perawat Melaksanakan Pendokumentasian Asuhan Keperawatan Berbasis Komputer. Jurnal Pendidikan - Teori, Penelitian, Dan Pengembangan, 1(10), 19261934. https://doi.org/10.17977/jp.v1i10.6967

Hastuti, W. (2024). Hubungan Motivasi Dengan Pendokumentasian Re-Assessment Risiko Jatuh. Jurnal Ilmu Kesehatan (JIKA), 3(1).

Hariyati, R. T. S., Malawat, K. Y., Purwandari, R., & Afifah, E. (2019). Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study. International Journal of Nursing and Health Services (IJNHS), 1(2), 32–39. https://doi.org/10.35654/ijnhs.v1i2.46

Herlina, E. (2023). Dampak Penggunaan Rekam Medis Elektronik Terhadap Beban Kerja Perawat Di Rumah Sakit Prikasih. Journal Of Management Nursing, 2(4), 253–260.

Hidayat. (2018) Metodelogi Penelitian Keperawatan dan Kesehatan. Jakarta: Salemba Medika.

Hidayat, A. A. (2021). Dokumentasi Keperawatan; Aplikasi Praktik Klinik. Health Books Publishing.

Iin Ariestin. (2022). Analisis Faktor-Faktor Yang Mempengaruhi Sikap Dan Niat Penggunaan Rekam Medis Elektronik Di Rs Pku Muhammadiyah Surakarta.

Jhonson W.G, (2021). Effect of Electronic Medical Records on Nurses’ Job. Vol 4, No. 3 The_Effect_of_Electronic_Medical_Records_on_Nurses.pdf Published: June 9, 2021 Diakses pada 12 Februari 2015.

Jip, P. S. (2024). Faktor–Faktor yang Berhubungan dengan Tingkat Kesiapan Petugas Kesehatan Terhadap Implementasi Rekam Medis Elektronik di RSKD Ibu dan Anak Pertiwi Kota Makassar Tahun 2023= Factors Associated with the Level of Readiness of Health Workers Regarding the Implementation of Electronic Medical Records at RSKD Pertiwi Makassar for Mothers and Children in 2023 (Doctoral dissertation, Universitas Hasanuddin).

Kemenkes (2022) Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis. Indonesia.

Kirana, S. R. D., & Sari, I. (2024). Pengaruh Metode Technology Acceptance Model (TAM) Terhadap Pengguna Rekam Medis Elektronik Di Rumah Sakit X. Prepotif: Jurnal Kesehatan Masyarakat, 8(3), 5919-5925.

Wirajaya, M. K., & Nuraini, N. (2019). Faktor faktor yang mempengaruhi ketidaklengkapan rekam medis pasien pada rumah sakit di Indonesia. Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), 165-165.

Yoga, V., Jaka, B., & Yanti, M. (2021). Analisis Kesiapan Penerapan Rekam Medis Elektronik (Rme)Di Rsup Dr. M. Djamil Padang. B-Dent: Jurnal Kedokteran Gigi Universitas Baiturrahmah, 8(1), 71–82. https://doi.org/10.33854/jbd.v8i1.598