Analysis of Factors Influencing Compliance with Electronic Medical Record Documentation by Nurses and Midwives in the Inpatient Department of Siloam Hospital Bangka

Novia Winardi, Sumijatun Sumijatun, Dedy Nugroho, Thika Marliana

Abstract


Documentation using Electronic Medical Records (EMR) significantly improves the quality of patient medical record completion. Siloam Hospital Bangka has implemented EMR; however, several challenges have arisen in its application within the inpatient department. This study aims to analyze the factors influencing compliance with EMR documentation among nurses and midwives in the inpatient department, focusing on aspects of knowledge, motivation, supervision, and infrastructure availability. This study employs a quantitative approach with a cross-sectional design. The sample consists of 33 nurses and midwives in the inpatient department, selected using a total sampling technique. Data were collected through questionnaires and an audit observation checklist of inpatient medical records during the period from January 15 to January 22, 2025. Fisher’s exact test and multiple logistic regression were used to determine the dominant variables influencing documentation compliance. The research results indicate a significant relationship between knowledge (p-value = 0.000; OR = 184.000) and supervision (p-value = 0.000; OR = 46.000) with nurses and midwifes compliance in documentation. However, no significant relationship was found between motivation or infrastructure availability and documentation compliance. This study concludes that documentation compliance is influenced by knowledge and supervision, with knowledge being the most dominant factor. Since documentation compliance in electronic medical records supports the quality of healthcare services at Siloam Hospital Bangka, the hospital is recommended to implement regular training programs on the use of electronic medical records.

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References


Agarta, A. and Febriani, N. (2019) ‘Kepuasan Perawat Mendokumentasikan Asuhan Keperawatan dengan Metode Electronic Health Record di Rumah Sakit’, Jurnal Ilmiah Ilmu Keperawatan Indonesia, 9, pp. 594–600.

Anila, Kusumajaya, H. and Maryana (2023) ‘FAKTOR-FAKTOR YANG BERHUBUNGAN DENGAN KETIDAKLENGKAPAN DOKUMENTASI ASUHAN KEPERAWATAN DI RUANG RAWAT INAP’, Jurnal Penelitian Perawat Profesional, 5, pp. 627–636. Availableat:http://jurnal.globalhealthsciencegroup.com/index.php/JPPP.

Darmawan, V.I. (2019) Hubungan antara Motivasi Perawat dengan Kelengkapan Pendokumentasian Asuhan Keperawatan secara Elektronik di Instalasi Rawat Inap RS Paru Jember. Malang.

Daryana et al. (2024) ‘FAKTOR-FAKTOR YANG MEMPENGARUHI KEPATUHAN PERAWAT DALAM PENDOKUMENTASIAN ASUHAN KEPERAWATAN PADA ELEKTRONIK REKAM MEDIS DI RSUD PAMEUNGPEUK GARUT’, Indonesian Nursing Journal of Education and Clinic, 4(1), pp. 70–87.

Furroidah, F., Maulidia, R. and Maria, L. (2023) ‘HUBUNGAN KARAKTERISTIK PERAWAT DENGAN TINGKAT KEPATUHAN DALAM MENERAPKAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN’, Jurnal Ilmiah Kesehatan Media Husada, pp. 26–38.

Hussein, S.Z. et al. (2021) ‘Patient Care Delivery: Electronic Nursing Documentation in Malaysia’, Makara Journal of Health Research, 25, pp. 101–106. Available at: https://doi.org/10.7454/msk.v25i2.1288.

Janett, R.S. and Yeracaris, P.P. (2020) ‘Electronic medical records in the american health system: Challenges and lessons learned’, Ciencia e Saude Coletiva, 25(4), pp. 1293–1304. Available at: https://doi.org/10.1590/1413-81232020254.28922019.

Kodama, K. et al. (2023) ‘Impact of an Electronic Medical Record–Connected Questionnaire on Efficient Nursing Documentation: Usability and Efficacy Study’, JMIR Nursing, 6(1). Available at: https://doi.org/10.2196/51303.

Laila, M.I.K. et al. (2024) ‘Faktor Penghambat Pelaksanaan Rekam Medis Elektronik di Rumah Sakit : Narrative Review’, Jurnal Manajemen Informasi Kesehatan Indonesia, 12, pp. 65–71.

Loblobly, E.M. (2021) HUBUNGAN KARAKTERISTIK PERAWAT DAN SUPERVISI KEPALA RUANG DENGAN KEPATUHAN PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI RUMAH SAKIT HARAPAN MAGELANG.

Menteri Kesehatan Republik Indonesia (2022) ‘PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA NOMOR 24 TAHUN 2022 TENTANG REKAM MEDIS’.

Orangbio, T.S., Wagey, F.W. and Vanda Doda, D.D. (2023) ‘FAKTOR-FAKTOR YANG MEMENGARUHI ANALISIS KELENGKAPAN PENGISIAN REKAM MEDIS ELEKTRONIK INSTALASI RAWAT JALAN RSUP PROF Dr. R.D KANDOU MANADO’, Jurnal Kesehatan Tambusai, 4, pp. 1210–1223.




DOI: https://doi.org/10.52643/joaf.v4i2.7234

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