Hubungan pengetahuan perawat dengan kepatuhan pendokumentasian asuhan keperawatan pada sistem emr =Elecronic medical record

Rozawati, Desi and situmorang, Elisda (2025) Hubungan pengetahuan perawat dengan kepatuhan pendokumentasian asuhan keperawatan pada sistem emr =Elecronic medical record. Bachelor thesis, Universitas Pelita Harapan.

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Abstract

Latar Belakang : Kelengkapan dokumentasi memengaruhi kualitas dan ketepatan informasi serta mengurangi kemungkinan kesalahan dalam proses dokumentasi asuhan keperawatan. Rumah Sakit Siloam Jambi telah menerapkan sistem pendokumentasian berbasis Electronic Medical Record (EMR). Namun, ditemukan ketidaksesuaian antara implementasi keperawatan yang telah dilakukan oleh perawat dengan pendokumentasian asuhan keperawatan. Selain itu, terdapat perubahan signifikan dari sistem berbasis kertas (paper- based) ke sistem berbasis elektronik (electronic-based), serta pemahaman yang masih kurang tentang pengisian formulir pada EMR. Kelengkapan pendokumentasian yang belum optimal, dengan target minimal 98-100%, menjadi perhatian utama. Hingga saat ini, belum dilakukan evaluasi terkait hubungan antara pengetahuan perawat dengan kepatuhan dalam pendokumentasian menggunakan EMR di Rumah Sakit Siloam Jambi. Tujuan: Penelitian bertujuan untuk mengidentifikasi hubungan antara pengetahuan perawat dengan kepatuhan pendokumentasian asuhan keperawatan pada EMR. Metode: Penelitian ini menggunakan desain kuantitatif korelasional dengan pendekatan cross-sectional. Populasi penelitian ini adalah perawat yang bekerja di ruang rawat inap dan rawat jalan di Rumah Sakit Siloam Jambi, berjumlah 97 perawat, dengan teknik pengumpulan sampling adalah total sampling. Analisis data dilakukan menggunakan yaitu univariat dan bivariat dengan analisa uji chi- square. Hasil: Berdasarkan uji Chi-Square diperoleh (p value = 0.995) lebih besar dari (p value 0.005) yang menyatakan tidak adanya hubungan antara pengetahuan dengan kepatuhan dalam pendokumentasian asuhan keperawatan. Saran : Diharapkan pihak rumah sakit dapat memfasilitasi perawat dengan diadakan pelatihan,seminar,supervisi,reward dan meningkatkan sarana prasarana untuk pemenuhan dan peningkatan pelayanan di rumah sakit/Background: Completeness of documentation affects the quality and accuracy of information and reduces the possibility of errors in the nursing care documentation process. Siloam Jambi Hospital has implemented an Electronic Medical Record (EMR)-based documentation system. However, there was a discrepancy between the implementation of nursing that had been carried out by nurses and the documentation of nursing care. In addition, there was a significant change from a paper-based system to an electronic-based system, as well as a lack of understanding about filling out forms on the EMR. The completeness of documentation that is not optimal, with a minimum target of 98-100%, is a major concern. Until now, there has been no evaluation regarding the relationship between nurses' knowledge and compliance in documentation using EMR at Siloam Jambi Hospital. Objective: The study aims to identify the relationship between nurses' knowledge and compliance in documenting nursing care in EMR. Method: This study used a quantitative correlational design with a cross-sectional approach. The population of this study were nurses working in inpatient and outpatient rooms at Siloam Jambi Hospital, totaling 97 nurses, with a total sampling technique. Data analysis was carried out using univariate and bivariate with chi-square test analysis. Results: Based on the Chi-Square test, it was obtained (p value = 0.995) greater than (p value 0.005) which stated that there was no relationship between knowledge and compliance in documenting nursing care. Suggestion: It is expected that the hospital can facilitate nurses by holding training, seminars, supervision, rewards and improving facilities and infrastructure to fulfill and improve services in the hospital.
Item Type: Thesis (Bachelor)
Creators:
Creators
NIM
Email
ORCID
Rozawati, Desi
01502230044
desirozawati187@gmail.com
UNSPECIFIED
situmorang, Elisda
01502230045
Elisda.situmorang@gmail.com
UNSPECIFIED
Contributors:
Contribution
Contributors
NIDN/NIDK
Email
UNSPECIFIED
Hutapea, Adventina
UNSPECIFIED
adventina.hutapea@uph.edu
UNSPECIFIED
Zega, windy
20190041
windy.zega@uph.edu
Uncontrolled Keywords: dokumentasi keperawatan; eletronic medical record; Kepatuhan;Pengetahuan;Perawat
Subjects: R Medicine > R Medicine (General)
R Medicine > RT Nursing
R Medicine > RZ Other systems of medicine
Divisions: University Subject > Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing
Current > Faculty/School - UPH Karawaci > Faculty of Nursing > Nursing
Depositing User: Desi Rozawati
Date Deposited: 08 Jul 2025 06:41
Last Modified: 08 Jul 2025 06:41
URI: http://repository.uph.edu/id/eprint/69093

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