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Abstract

Completeness of medical records is one of the important factors in improving the quality of health services. Despite its importance, incomplete documentation remains a prevalent issue, and the adoption of Electronic Medical Records (EMRs) is anticipated to address this challenge. This study is a narrative review and utilized the PRISMA 2020 flow diagram for literature selection. Articles were sourced from the ProQuest and Scopus databases for articles published in 2019-2024. From an initial selection of 431 articles, eight articles met the inclusion criteria for this study. The analysis of these studies shows that the implementation of electronic medical records positively influences the medical record documentation’s completeness. Among the eight reviewed articles, seven articles demonstrated significant improvements in the completeness of medical documentation following electronic medical record implementation. Continuous evaluation and identification of supporting factors for implementing electronic medical records in improving medical record documentation’s completeness need to be studied further.

References

Alsohime, F. et al. (2019) ‘Satisfaction and perceived usefulness with newly-implemented Electronic Health Records System among pediatricians at a university hospital’, Computer Methods and Programs in Biomedicine, 169, pp. 51–57. Available at: https://doi.org/10.1016/j.cmpb.2018.12.026.

Amin, M., Setyonugroho, W. and Hidayah, N. (2021) ‘Implementasi Rekam Medik Elektronik: Sebuah Studi Kualitatif’, JATISI (Jurnal Teknik Informatika dan Sistem Informasi), 8(1), pp. 430–442. Available at: https://doi.org/10.35957/jatisi.v8i1.557.

Butler, M.J. et al. (2024) ‘Implementation of major trauma app: usability and data completeness’, BMC Emergency Medicine, 24(1), p. 136. Available at: https://doi.org/10.1186/s12873-024-01022-w.

Carayon, P. et al. (2015) ‘Impact of electronic health record technology on the work and workflow of physicians in the intensive care unit’, International Journal of Medical Informatics, 84(8), pp. 578–594. Available at: https://doi.org/10.1016/j.ijmedinf.2015.04.002.

Cheung, K. and Yip, C.S. (2024) ‘Documentation Completeness and Nurses’ Perceptions of a Novel Electronic App for Medical Resuscitation in the Emergency Room: Mixed Methods Approach’, JMIR mHealth and uHealth, 12, p. e46744. Available at: https://doi.org/10.2196/46744.

Darsono, D. (2024) ‘Evaluasi Rekam Medis Elektronik RS Bethesda Yogyakarta dalam Upaya Mendukung Percepatan Transformasi Kesehatan Digital’, Journal of Information Systems for Public Health, 9(1), p. 20. Available at: https://doi.org/10.22146/jisph.91784.

Garavand, A. et al. (2016) ‘Readiness of Shiraz teaching hospitals to implement Electronic Medical Record (EMR)’, Health Management & Information Science Journal (HMIS), 3(3), pp. 82–88. Available at: https://jhmi.sums.ac.ir/article_42671.html.

Hartono, L.V., Aribowo, N.K.P. and Dzikrah, R. (2024) ‘Analisis Tantangan Penerapan Transformasi Teknologi Kesehatan di Puskesmas sebagai Program Kesehatan Berbasis Masyarakat: Kajian Literatur’. Available at: https://www.researchgate.net/publication/387067636_Analisis_Tantangan_Penerapan_Transformasi_Teknologi_Kesehatan_di_Puskesmas_sebagai_Program_Kesehatan_Berbasis_Masyarakat_Kajian_Literatur.

Joukes, E. et al. (2019) ‘Impact of Electronic versus Paper-Based Recording before EHR Implementation on Health Care Professionals’ Perceptions of EHR Use, Data Quality, and Data Reuse’, Applied Clinical Informatics, 10(02), pp. 199–209. Available at: https://doi.org/10.1055/s-0039-1681054.

Kaazan, P. et al. (2021) ‘Assessing effectiveness and patient perceptions of a novel electronic medical record for the management of inflammatory bowel disease’, JGH Open, 5(9), pp. 1063–1070. Available at: https://doi.org/10.1002/jgh3.12631.

Kapitan, R., Farich, A. and Perdana, A.A. (2023) ‘Analisis Kesiapan Penerapan Rekam Medis Elektronik RSUD Bandar Negara Husada Provinsi Lampung Tahun 2023’, Jurnal Kebijakan Kesehatan Indonesia, 12(4), p. 205. Available at: https://doi.org/10.22146/jkki.89841.

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

Koh, J. and Ahmed, M. (2021) ‘Improving clinical documentation: introduction of electronic health records in paediatrics’, BMJ Open Quality, 10(1), p. e000918. Available at: https://doi.org/10.1136/bmjoq-2020-000918.

Muallem, Y. et al. (2017) ‘Auditing The Completeness and Legibility of Computerized Radiological Request Forms’, Journal of Medical Systems, 41(12), p. 199. Available at: https://doi.org/10.1007/s10916-017-0826-0.

Mullins, J. et al. (2021) ‘Assessing the completeness of periodontal disease documentation in the EHR: a first step in measuring the quality of care’, BMC Oral Health, 21(1), p. 282. Available at: https://doi.org/10.1186/s12903-021-01633-w.

Preethi, M.M., Bhoomadevi, A. and Amutha, A. (2021) ‘Electronic Medical Records (EMR) over manual documentation of in-patient records: a scientific insight’, Turkish Journal of Computer and Mathematics Education, 12(11), pp. 3274-3285. Available at: https://www.proquest.com/docview/2623921985/abstract/928732D8E7C4C19PQ/1?accountid=17242&sourcetype=Scholarly Journals#.

Rahmawati, N., Fithri, I. and Pratama, T.W.Y. (2021) ‘Analisis Ketidaklengkapan Rekam Medis Rawat Inap di Rumah Sakit’, Indonesian Journal of Health Information Management, 1(2). Available at: https://doi.org/10.54877/ijhim.v1i2.14.

Shauer, D. et al. (2023) ‘Quality of Electronic TB Register Data Compared with Paper-Based Records in the Kyrgyz Republic’, Tropical Medicine and Infectious Disease, 8(8), p. 416. Available at: https://doi.org/10.3390/tropicalmed8080416.

Siregar, R.A. (2024) ‘Penerapan Permenkes Nomor 24 Tahun 2022 Tentang Rekam Medis Terhadap Efektivitas Pelayanan Kesehatan’, Jurnal Ilmu Hukum Kyadiren, 5(2). Available at: https://doi.org/10.46924/jihk.v5i2.182.

Sockolow, P.S. et al. (2014) ‘Impact of Homecare Electronic Health Record on Timeliness of Clinical Documentation, Reimbursement, and Patient Outcomes’, Applied Clinical Informatics, 05(02), pp. 445–462. Available at: https://doi.org/10.4338/ACI-2013-12-RA-0106.

Wikansari, N. and Febrianta, N. (2024) ‘Analisis Kesiapan Implementasi Rekam Medis Elektronik di Puskesmas Pajangan Kabupaten Bantul’, Journal Health Information Management Indonesian (JHIMI), 3(1), pp. 72–76. Available at: https://doi.org/10.46808/jhimi.v3i1.169.

Wirajaya, M.K.M. and Dewi, N.M.U.K. (2019) ‘Analisis Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Rumah Sakit Dharma Kerti Tabanan’, Jurnal ARSI : Administrasi Rumah Sakit Indonesia, 6(1). Available at: https://doi.org/10.7454/arsi.v6i1.3553.

Witkowski, C. et al. (2021) ‘Comparison of the quality of documentation between electronic and paper medical records in orthopaedic trauma patients’, Australian Health Review, 46(2), pp. 204–209. Available at: https://doi.org/10.1071/AH21112.

Wurster, F. et al. (2024) ‘The Implementation of an Electronic Medical Record in a German Hospital and the Change in Completeness of Documentation: Longitudinal Document Analysis’, JMIR Medical Informatics, 12, p. e47761. Available at: https://doi.org/10.2196/47761.

Bahasa Abstract

Kelengkapan rekam medis merupakan salah satu faktor penting dalam upaya peningkatan kualitas pelayanan kesehatan. Ketidaklengkapan dokumentasi rekam medis masih sering ditemukan di berbagai fasilitas pelayanan kesehatan sehingga Rekam Medis Elektronik (RME) diharapkan dapat menjadi solusi. Studi ini merupakan kajian literatur yang disusun dengan menggunakan diagram alur pencarian literatur sesuai format PRISMA 2020. Strategi pencarian artikel dilakukan melalui dua basis data, yaitu ProQuest dan Scopus terhadap artikel yang dipublikasikan pada tahun 2019-2024. Hasil dari total 431 artikel yang diseleksi, delapan artikel memenuhi kriteria inklusi untuk dianalisis lebih lanjut. Hasil kajian terhadap artikel-artikel tersebut menunjukkan bahwa penerapan RME berdampak positif terhadap kelengkapan dokumentasi rekam medis. Total delapan artikel yang dianalisis terdapat tujuh artikel yang menunjukkan bahwa penerapan RME secara signifikan meningkatkan kelengkapan dokumentasi medis. Evaluasi berkelanjutan dan identifikasi terhadap faktor-faktor yang mendukung implementasi RME dalam memperbaiki kelengkapan dokumentasi rekam medis perlu dilakukan pada penelitian selanjutnya.

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