Pengaruh Dokumentasi Keperawatan Elektronik Terhadap Peningkatan Pendokumentasian Asuhan Keperawatan: Systematic Review

Agustina - Agustina

Abstract


 

ABSTRACT

 

This research aims to conduct a systematic review on the impact of implementing electronic nursing documentation on the improvement of nursing care documentation. The systematic method involves searching and critically analyzing relevant scientific literature. Literature searches were performed on various scientific journal databases, research articles, and related publications from a specific timeframe. Strict inclusion and exclusion criteria were applied to ensure the selection of studies aligning with the research focus. After selection, data analysis was conducted by detailing the research outcomes, including study design, population, electronic documentation implementation methods, and its impact on enhancing nursing care documentation. The results of this systematic review indicate that the implementation of electronic nursing documentation has a positive impact on improving nursing care documentation. Electronic systems help reduce documentation errors, enhance information accessibility, and provide support in clinical decision-making. Supporting factors and implementation barriers were also identified to provide further insights. Consequently, the findings of this research make a significant contribution to understanding the influence of electronic nursing documentation on the enhancement of nursing care documentation. The practical implications of this study can serve as a foundation for developing policies, guidelines, and implementing more effective electronic nursing documentation systems in healthcare settings.

Keywords: Nurse; Electronic;Documentation

 

ABSTRAK

Penelitian ini bertujuan untuk melakukan tinjauan sistematis review terhadap pengaruh dokumentasi keperawatan elektronik terhadap peningkatan pendokumentasian asuhan keperawatan. Metode sistematis ini dilakukan dengan melakukan pencarian dan analisis kritis terhadap literatur ilmiah yang relevan. Pencarian literatur dilakukan pada basis data berbagai jurnal ilmiah, artikel penelitian, dan publikasi terkait sejak periode tertentu. Kriteria inklusi dan eksklusi yang ketat diterapkan untuk memastikan pemilihan studi yang sesuai dengan fokus penelitian. Setelah seleksi, analisis data dilakukan dengan merinci hasil penelitian yang mencakup desain studi, populasi, metode implementasi dokumentasi elektronik, dan dampaknya terhadap peningkatan pendokumentasian asuhan keperawatan. Hasil tinjauan sistematis ini menunjukkan bahwa implementasi dokumentasi keperawatan elektronik memiliki dampak positif pada peningkatan pendokumentasian asuhan keperawatan. Sistem elektronik membantu mengurangi kesalahan dokumentasi, meningkatkan aksesibilitas informasi, dan memberikan dukungan dalam pengambilan keputusan klinis. Faktor-faktor pendukung dan hambatan implementasi juga diidentifikasi untuk memberikan wawasan lebih lanjut. Dengan demikian, temuan dari penelitian ini memberikan kontribusi penting dalam pemahaman terhadap pengaruh dokumentasi keperawatan elektronik terhadap peningkatan pendokumentasian asuhan keperawatan. Implikasi praktis dari hasil penelitian ini dapat digunakan sebagai dasar untuk pengembangan kebijakan, pedoman, dan implementasi sistem dokumentasi keperawatan elektronik yang lebih efektif di lingkungan perawatan kesehatan.

Kata kunci: Perawat; Elektronik; Dokumentasi


References


DAFTAR PUSTAKA

Rahmi U. Dokumentasi Keperawatan. Pertama. Sari Fatmawati B, editor. Jakarta: Bumi Medika; 2022. 270 p.

Tasew H, Mariye T, Teklay G. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Res Notes [Internet]. 2019;12(1):1–6. Available from: https://doi.org/10.1186/s13104-019-4661-x

Wulandari DF, Handiyani H. Pengembangan Dokumentasi Keperawatan Berbasis Elektronik Di RS X Kota Depok Dengan Menggunakan Teori Perubahan Lewins. J Keperawatan Glob. 2019;4(1):55–64.

Saraswasta IWG, Hariyati RTS. A systematic review of the implementation of electronic nursing documentation toward patient safety. Enfermería Clínica [Internet]. 2021;31:S205–9. Available from: https://www.sciencedirect.com/science/article/pii/S1130862120305854

Martyn JA, Paliadelis P, Perry C. The safe administration of medication: Nursing behaviours beyond the five-rights. Nurse Educ Pract [Internet]. 2019;37:109–14. Available from: https://www.sciencedirect.com/science/article/pii/S1471595317308673

Martyn JA, Paliadelis P. Safe medication administration: Perspectives from an appreciative inquiry of the practice of registered nurses in regional Australia. Nurse Educ Pract [Internet]. 2019;34:111–6. Available from: https://www.sciencedirect.com/science/article/pii/S1471595318300908

McCarthy B, Fitzgerald S, O’Shea M, Condon C, Hartnett-Collins G, Clancy M, et al. Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. J Nurs Manag. 2019;27(3):491–501.

Aris Winata IMN, Hariyati RTS. Nurse satisfaction level using electronic nursing documentation. Enfermería Clínica [Internet]. 2021;31:S109–12. Available from: https://www.sciencedirect.com/science/article/pii/S1130862120305647

Misto K, Padula C, Bryand E, Nadeau K. Nurses’ Perception of the Impact of Electronic Documentation on the Nurse-Patient Relationship. J Nurs Care Qual. 2019;34(2):163–8.

De Groot K, Douma J, Paans W, Francke AL. Patient participation in electronic nursing documentation: An interview study among home-care patients. Heal Expect. 2022;25(4):1508–16.

Bruylands M, Paans W, Hediger H, Müller-Staub M. Effects on the quality of the nursing care process through an educational program and the use of electronic nursing documentation. Int J Nurs Knowl. 2019 Oct;24(3):163–70.

Burri B, Odenbreit M, Schärer S. [Electronic nursing documentation. No one has the right to reverse the information]. Krankenpfl Soins Infirm. 2019;103(4):16–8.

Yang Y, Bass EJ, Bowles KH, Sockolow PS. Impact of Home Care Admission Nurses’ Goals on Electronic Health Record Documentation Strategies at the Point of Care. CIN - Comput Informatics Nurs. 2019;37(1):39–46.

Ebbers T, Takes RP, Smeele LE, Kool RB, van den Broek GB, Dirven R. The implementation of a multidisciplinary, electronic health record embedded care pathway to improve structured data recording and decrease electronic health record burden. Int J Med Inform [Internet]. 2024;184:105344. Available from: https://www.sciencedirect.com/science/article/pii/S1386505624000078

Goldman DA, Panageas KS. Electronic Medical Record Documentation and Provider Burnout. JCO Oncol Pract. 2021;17(3):158–9.

Lindsay MR, Lytle K. Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record. Appl Clin Inform. 2022 May;13(3):711–9.

Ibrahim S, Donelle L, Regan S, Sidani S. Predicting Registered Nurses’ Behavioural Intention to Use Electronic Documentation System in Home Care: Application of an Adapted Unified Theory of Acceptance and Use of Technology Model. Can J Nurs Leadersh. 2019 Jun;32:48–70.

Kelley TF, Brandon DH, Docherty SL. Electronic nursing documentation as a strategy to improve quality of patient care. J Nurs Scholarsh an Off Publ Sigma Theta Tau Int Honor Soc Nurs. 2019 Jun;43(2):154–62.

D’Agostino F, Zeffiro V, Cocchieri A, Vanalli M, Ausili D, Vellone E, et al. Impact of an Electronic Nursing Documentation System on the Nursing Process Accuracy. In 2019. p. 247–52.

Häyrinen K, Lammintakanen J, Saranto K. Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. Int J Med Inform [Internet]. 2010;79(8):554–64. Available from: https://www.sciencedirect.com/science/article/pii/S1386505610000985

Shafiee M, Shanbehzadeh M, Nassari Z, Kazemi-Arpanahi H. Development and evaluation of an electronic nursing documentation system. BMC Nurs. 2022;21(1):1–12.




DOI: http://dx.doi.org/10.33846/sf.v15i2.4779

Refbacks

  • There are currently no refbacks.


Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

___________________________________________________________________________________________________________________________________

Jurnal Penelitian Kesehatan SUARA FORIKES (Journal of Health Research FORIKES VOICE), e-ISSN: 2502-7778, p-ISSN 2086-3098
Volume 1-6 (2010-2015) are available at http://suaraforikes.webs.com)
+6282132259611 (phone and WhatsApp)

___________________________________________________________________________________________________________________________________