Kepatuhan terhadap Standar Dokumentasi dalam Rekam Medis Elektronik: Suatu Tinjauan Scoping
DOI:
https://doi.org/10.32583/keperawatan.v17i3.3737Keywords:
kepatuhan dokumentasi, keselamatan pasien, kualitas pelayanan kesehatan, rekam medis elektronik, scoping reviewAbstract
Kepatuhan terhadap standar dokumentasi dalam Rekam Medis Elektronik (EHR) sangat penting untuk keselamatan pasien dan kualitas layanan. Namun, tantangan seperti beban administratif, keterbatasan teknologi, dan kebijakan institusi yang bervariasi memengaruhi tingkat kepatuhan tenaga kesehatan. Dokumentasi yang akurat mendukung pengambilan keputusan klinis dan menurunkan risiko kesalahan medis. Studi ini bertujuan mengidentifikasi faktor-faktor utama yang memengaruhi kepatuhan terhadap standar EHR, mengevaluasi tantangan teknologi dan sumber daya manusia, serta mengidentifikasi kesenjangan penelitian. Metode: Mengikuti pedoman JBI dan PRISMA-ScR, tinjauan ini menelaah literatur dari ProQuest, ScienceDirect, BMC, dan sumber lain. Dari 961 artikel, 22 dipilih untuk telaah penuh, dan 10 dianalisis kritis (1 kualitatif, 1 cross-sectional, dan 8 quasi-eksperimental). Hasil: Kepatuhan dipengaruhi oleh kebijakan institusi, beban administratif, integrasi sistem, dan pelatihan. Sistem EHR yang tidak terintegrasi memperbesar kesalahan. Tantangan lain mencakup privasi data (HIPAA, GDPR) dan keterbatasan pelatihan. Ditemukan kesenjangan terkait efektivitas jangka panjang kepatuhan terhadap outcome pasien. Kesimpulan: Diperlukan pendekatan multidimensional, termasuk penguatan kebijakan, optimalisasi teknologi, dan pelatihan berkelanjutan. Automasi dan AI berpotensi mengurangi beban dokumentasi dan meningkatkan kepatuhan.
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