Analisis Dokumentasi Rekam Medis Elektronik di Fasilitas Pelayanan Kesehatan : Literature Review
Analysis of Electronic Medical Record’s Documentation In Health Care Facilities : Literature Review
Abstract
Latar belakang: Penggunaan teknologi informasi menjadi hal penting dalam dokumentasi data rekam medis. Rekam medis elektronik yang interoperable dapat memecahkan masalah disintegrasi data. Kelengkapan, keakuratan, dan kecepatan akses rekam medis elektronik dapat menjaga kesinambungan layanan kesehatan.
Tujuan: Penelitian bertujuan untuk mengetahui potensi manfaat, permasalahan, dan solusi penerapan dokumentasi rekam medis elektronik di fasilitas pelayanan kesehatan.
Metode: Literature review ini menggunakan metode PRISMA. Database yang digunakan adalah Pubmed, JSTOR, Scopus, dan Google Scholar. Kata kunci yang digunakan “surgeon OR obstetrician OR gynecologist”, “electronic medical records OR paper medical record”, dan “documentation”.
Hasil: Kelengkapan dokumentasi rekam medis elektronik meningkatkan keselamatan pasien dan kesinambungan pelayanan kesehatan. Semakin lengkap isi rekam medis, semakin banyak waktu yang diperlukan untuk mengisi rekam medis tersebut. Berbagai penelitian telah dilakukan untuk mengetahui manfaat-manfaat, permasalahan, serta solusi dalam penerapan dokumentasi rekam medis elektronik.
Kesimpulan: Integrasi data dan kesinambungan pelayanan dapat tercapai dengan penerapan dokumentasi rekam medis elektronik yang lengkap dan akurat di seluruh fasilitas pelayan kesehatan. Solusi – solusi yang dipaparkan perlu dikaji sesuai kondisi masing – masing fasilitas pelayanan kesehatan.
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