Dampak Penggunaan Dokumentasi Keperawatan Elektronik terhadap Keselamatan Pasien: A Literature Review

Authors

  • Vinny Vionita Bawuno Fakultas Keperawatan, Universitas Hasanuddin Makassar
  • Kadek Ayu Erika Fakultas Keperawatan, Universitas Hasanuddin Makassar
  • Yuliana Syam Fakultas Keperawatan, Universitas Hasanuddin Makassar

DOI:

https://doi.org/10.32583/keperawatan.v15i2.825

Keywords:

catatan kesehatan elektronik, dokumentasi keperawatan elektronik, keselamatan pasien

Abstract

Era transformasi menuntut pelayanan berbasis teknologi, termasuk sistem pendokumentasian berbasis elektronik. Terdapat berbagai dampak dalam penggunaan catatan keperawatan elektronik yang berimplikasi terhadap keselamatan pasien. Studi ini bertujuan untuk untuk mengetahui dampak penggunaan dokumentasi keperawatan elektronik terhadap keselamatan pasien. Digunakan metode pendekatan literature review dengan pencarian artikel pada lima database elektronik: PubMed, ProQuest, DOAJ, Scopus dan GARUDA. Teridentifikasi 1.019 artikel, yang kemudian dilakukan skrining berdasarkan kriteria inklusi dan eksklusi. Hasil menunjukkan tujuh studi memenuhi kriteria, termasuk Lima studi cross-sectional, satu studi kualitatif dan satu studi mix-method. Lima studi menyimpulkan bahwa pendokumentasian berbasis elektronik berimplikasi terhadap peningkatan keselamatan pasien. Empat studi menyoroti penurunan keselamatan pasien pada penggunaan dokumentasi berbasis elektronik. Kajian ini menemukan wawasan baru yang komprehensif terkait dampak penggunaan dokumentasi keperawatan elektronik baik yang menguntungkan maupun merugikan dalam upaya menjaga keselamatan pasien.  Sehingga, ini dapat berguna untuk rencana pengembangan strategi penerapan dokumentasi keperawatan berbasis elektronik.

References

Alpert, J. (2016). The electronic medical record in 2016: Advantages and disadvantages. Digital Medicine, 2(2). https://doi.org/10.4103/2226-8561.189504

Anthony, D. L., & Stablein, T. (2016). Privacy in practice: professional discourse about information control in health care. Journal of Health, Organisation and Management, 30(2). https://doi.org/10.1108/JHOM-12-2014-0220

Ausserhofer, D., Favez, L., Simon, M., & Zúñiga, F. (2021). Electronic Health Record Use in Swiss Nursing Homes and Its Association With Implicit Rationing of Nursing Care Documentation: Multicenter Cross-sectional Survey Study. JMIR Medical Informatics, 9(3), e22974. https://doi.org/10.2196/22974

Bani Issa, W., Al Akour, I., Ibrahim, A., Almarzouqi, A., Abbas, S., Hisham, F., & Griffiths, J. (2020). Privacy, confidentiality, security and patient safety concerns about electronic health records. International Nursing Review, 67(2), 218–230. https://doi.org/10.1111/inr.12585

Bowman, S. (2013). Impact of electronic health record systems on information integrity: quality and safety implications. In Perspectives in health information management / AHIMA, American Health Information Management Association (Vol. 10).

Campanella, P., Lovato, E., Marone, C., Fallacara, L., Mancuso, A., Ricciardi, W., & Specchia, M. L. (2016). The impact of electronic health records on healthcare quality: A systematic review and meta-analysis. European Journal of Public Health, 26(1). https://doi.org/10.1093/eurpub/ckv122

Collins, S. A., Cato, K., Albers, D., Scott, K., Stetson, P. D., Bakken, S., & Vawdrey, D. K. (2013). Relationship between nursing documentation and patients’ mortality. American Journal of Critical Care, 22(4). https://doi.org/10.4037/ajcc2013426

Dudding, K. M., Gephart, S. M., & Carrington, J. M. (2018). Neonatal Nurses Experience Unintended Consequences and Risks to Patient Safety with Electronic Health Records. CIN - Computers Informatics Nursing, 36(4). https://doi.org/10.1097/CIN.0000000000000406

Eriyani. (2020). Bahan Ajar Dokumentasi Keperawatan. STIKes Binalita Sudama.

Gita Wardani, I., Kurniati, T., Sulaeman Program Studi Magister Keperawatan, S., Ilmu Keperawatan, F., Muhammadiyah Jakarta, U., Ahmad Dahlan, J. K., Ciputat Timur, K., & Tangerang Selatan, K. (2022). Kompetensi Perawat, Sarana Prasarana Terhadap Dokumentasi Keperawatan Elektronik, Dampaknya Pada Patient Safety. 14(September), 567–574. http://journal.stikeskendal.ac.id/index.php/Keperawatan

Han, J. E., Rabinovich, M., Abraham, P., Satyanarayana, P., Liao, T. V., Udoji, T. N., Cotsonis, G. A., Honig, E. G., & Martin, G. S. (2016). Effect of Electronic Health Record Implementation in Critical Care on Survival and Medication Errors. American Journal of the Medical Sciences, 351(6). https://doi.org/10.1016/j.amjms.2016.01.026

Hastuti, P., Kurniawati, Indraningsih, S., Utami, R., Pujiani, Rajin, M., Yuliani, E., Sugiarto, A., Muhsinah, S., Damayanti, E., SImbolon, S., Sitorus, J., Pranatha, A., & Sulastri. (2022). Proses Dokumentasi Keperawatan. Yayasan Kita Menulis.

Kaihlanen, A. M., Gluschkoff, K., Saranto, K., Kinnunen, U. M., & Heponiemi, T. (2021). The associations of information system’s support and nurses’ documentation competence with the detection of documentation-related errors: Results from a nationwide survey. Health Informatics Journal, 27(4). https://doi.org/10.1177/14604582211054026

Laukvik, L. B., Lyngstad, M., Rotegård, A. K., Slettebø, Å., & Fossum, M. (2022). Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review. BMC Nursing, 21(1), 84. https://doi.org/10.1186/s12912-022-00863-9

Lavander, P., Meriläinen, M., & Turkki, L. (2016). Working time use and division of labour among nurses and health-care workers in hospitals – a systematic review. Journal of Nursing Management, 24(8), 1027–1040. https://doi.org/10.1111/jonm.12423

McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., & Savage, E. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3), 491–501. https://doi.org/10.1111/jonm.12727

Nakate, G. M., Dahl, D., Petrucka, P., B. Drake, K., & Dunlap, R. (2015). The Nursing Documentation Dilemma in Uganda: Neglected but Necessary. A Case Study at Mulago National Referral Hospital. Open Journal of Nursing, 05(12), 1063–1071. https://doi.org/10.4236/ojn.2015.512113

Nguyen, L., Bellucci, E., & Nguyen, L. T. (2014). Electronic health records implementation: An evaluation of information system impact and contingency factors. In International Journal of Medical Informatics (Vol. 83, Issue 11). https://doi.org/10.1016/j.ijmedinf.2014.06.011

O’Brien, A., Weaver, C., Settergren, T., Hook, M. L., & Ivory, C. H. (2015). EHR Documentation: The Hype and the Hope for Improving Nursing Satisfaction and Quality Outcomes. Nursing Administration Quarterly, 39(4), 333–339. https://doi.org/10.1097/NAQ.0000000000000132

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. In The BMJ (Vol. 372). https://doi.org/10.1136/bmj.n71

Palojoki, S., Mäkelä, M., Lehtonen, L., & Saranto, K. (2017). An analysis of electronic health record-related patient safety incidents. Health Informatics Journal, 23(2). https://doi.org/10.1177/1460458216631072

Pandya, C., Clarke, T., Scarsella, E., Alongi, A., Amport, S. B., Hamel, L., & Dougherty, D. (2019). Ensuring effective care transition communication: Implementation of an electronic medical record–based tool for improved cancer treatment handoffs between clinic and infusion nurses. Journal of Oncology Practice, 15(5). https://doi.org/10.1200/JOP.18.00245

Schnock, K. O., Kang, M. J., Rossetti, S. C., Garcia, J., Lowenthal, G., Knaplund, C., Chang, F., Albers, D., Korach, T. Z., Zhou, L., Klann, J. G., Cato, K., Bates, D. W., & Dykes, P. C. (2021). Identifying nursing documentation patterns associated with patient deterioration and recovery from deterioration in critical and acute care settings. International Journal of Medical Informatics, 153. https://doi.org/10.1016/j.ijmedinf.2021.104525

Sharikh, E. A., Shannak, R., Suifan, T., & Ayaad, O. (2020). The impact of electronic medical records’ functions on the quality of health services. British Journal of Health Care Management, 26(2), 1–13. https://doi.org/10.12968/bjhc.2019.0056

Tubaishat, A. (2019). The effect of electronic health records on patient safety: A qualitative exploratory study. Informatics for Health and Social Care, 44(1), 79–91. https://doi.org/10.1080/17538157.2017.1398753

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Published

03/31/2023

How to Cite

Vinny Vionita Bawuno, Erika, K. A., & Yuliana Syam. (2023). Dampak Penggunaan Dokumentasi Keperawatan Elektronik terhadap Keselamatan Pasien: A Literature Review. Jurnal Keperawatan, 15(2), 661–670. https://doi.org/10.32583/keperawatan.v15i2.825