Perancangan prototipe pendokumentasian keperawatan berbasis rekam medis elektronik di rumah sakit x dengan menggunakan teori perubahan Lewins
Authors: Kehi Lusianus Demon , Yetti Krisna , Afriani Tuti , Wulandari Dyah Fitri 
Published: January 2025

Background: Nursing documentation is one of the crucial aspects in health services. This activity aims to record the nursing care process systematically, precisely, and accurately. Most hospitals still use paper-based documentation methods that have many weaknesses, so it is necessary to switch to a more efficient and effective method, namely electronic-based documentation.
Purpose: To design a prototype of nursing documentation based on electronic medical records in x hospital using Lewin's change theory.
Method: Nursing management residency activities were carried out in September-October 2024 at KiSA Depok hospital. This activity began with identifying problems through interview, observation and questionnaire methods. Interview activities were carried out with the head of the nursing division, the nursing committee and the head of the inpatient room. Observations were made on nursing care services in 3 inpatient rooms, namely the Amarilis room, the Asoka room, and the Aster room. The questionnaire was distributed via google form to all implementing nurses.
Results: Problem identification from several factors including the inpatient EMR team has not determined the concept of using electronic medical record-based nursing care standards and nursing staff have not received training in using electronic medical records. The limited number of computers in each room and the internet network is inadequate, there is no guidebook, standard operating procedures (SOP), use of EMR-based 3S nursing care standards, and there has been no determination of the time bone for implementing EMR in the hospital. In addition, there has been no design of EMR-based 3S nursing care standards and 3S data banks.
Conclusion: Documentation in the inpatient room is still paper-based, this method takes a long time, has a high potential for writing errors, absorbs large costs for paper procurement and requires large storage space. The solution to overcome this problem is to switch to an electronic-based documentation method.

Keywords: Documentation, Electronic; Nursing; Prototype; Design.

Pendahuluan: Pendokumentasian keperawatan merupakan salah satu aspek krusial dalam pelayanan kesehatan. Kegiatan ini bertujuan untuk mencatat proses asuhan keperawatan secara sistematis, tepat, dan akurat. Sebagian besar rumah sakit masih menggunakan metode pendokumentasian berbasis kertas yang memiliki banyak kelemahan, sehingga perlu beralih ke metode yang lebih efisien dan efektif yaitu pendokumentasian berbasis elektronik.
Tujuan: Untuk merancang prototipe pendokumentasian keperawatan berbasis rekam medis elektronik di rumah sakit x dengan menggunakan teori perubahan Lewins.
Metode: Kegiatan residensi manajemen keperawatan dilaksanakan pada 2 September-2 Oktober 2024 bertempat di RSUD KiSA Depok. Kegiatan ini diawali dengan melakukan identifikasi masalah melalui metode wawancara, observasi, dan kuesioner. Kegiatan wawancara dilakukan terhadap kepala bidang keperawatan, komite keperawatan, dan kepala ruangan rawat inap. Observasi dilakukan terhadap pelayanan asuhan keperawatan di 3 ruangan rawat inap, yaitu ruang Amarilis, ruang Asoka, dan ruang Aster. Kuesioner disebarkan melalui google form kepada seluruh perawat pelaksana.
Hasil: Identifikasi masalah dari beberapa faktor antara lain, tim RME rawat inap belum memutuskan konsep penggunaan standar asuhan keperawatan 3S (SDKI, SIKI, SLKI) berbasis rekam medis elektronik dan tenaga perawat belum dilatih mengenai penggunaan rekam medis elektronik. Masih terbatasnya jumlah komputer di setiap ruangan dan jaringan internet belum memadai, belum adanya panduan, SPO penggunaan standar asuhan keperawatan 3S berbasis RME, dan penetapan time bone implementasi RME di rawat inap. Selain itu, belum adanya desain standar asuhan keperawatan 3S berbasis RME dan bank data 3S.
Simpulan: Pendokumentasian di ruang rawat inap masih berbasis kertas, metode tersebut memakan waktu yang lama, potensi kesalahan penulisan tinggi, menyerap biaya yang besar untuk pengadaan kertas dan membutuhkan ruang penyimpanan yang besar. Solusi untuk mengatasi masalah tersebut adalah dengan beralih pada metode pendokumentasian berbasis elektronik.

Kata Kunci: Dokumentasi; Elektronik; Keperawatan; Prototipe; Rancangan.